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Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
Sm grade v avm
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Sm grade v avm

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  • 1. “ What are the indications for surgical treatment in a 16-year-old patient presenting with ICH due to a SM Grade V AVM?” EBS Meeting 19/05/11 Supervisor: Prof MK Morgan
  • 2. <ul><li>16F / nil PMH </li></ul><ul><li>Long standing left sided tinnitus </li></ul><ul><li>Collapse – CTB -> Posterior fossa haemorrhage and early HCP. </li></ul><ul><li>PFD and Rt frontal EVD insertion. </li></ul>What next?
  • 3. Searchable question P – pts with SM grade 5 AVM I – surgical intervention C – conservative management O – outcome (morbidity / mortality)
  • 4. <ul><li>Searchable question </li></ul><ul><li>“ What are the morbidity and mortality rates associated with resection of a SM grade V AVM? Do these justify surgical intervention? ” </li></ul><ul><li>Databases </li></ul><ul><li>Medline – using MeSH </li></ul><ul><li>Scopus using key articles and tracking citations </li></ul>
  • 5.  
  • 6. <ul><li>Medline </li></ul><ul><li>68 articles. </li></ul><ul><li>7 highly relevant. </li></ul><ul><li>Rest: </li></ul><ul><li>Not dealing with Intracranial AVM </li></ul><ul><li>Not dealing with surgery </li></ul><ul><li>Not in English </li></ul>
  • 7. <ul><li>Scopus </li></ul><ul><li>Key articles searched by title and tracked their citations. </li></ul><ul><li>Further 5 articles identified. </li></ul>
  • 8. <ul><li>Level of evidence </li></ul><ul><li>Level 1: 0 </li></ul><ul><li>Level 2: 0 </li></ul><ul><li>Level 3: The articles identified. </li></ul>
  • 9. NHMRC level of evidence
  • 10. <ul><li>Prospective cohort </li></ul><ul><li>631 consecutive patients with AVM </li></ul><ul><li>1942- 2005 </li></ul><ul><li>63 pts with high – grade AVMs identified (Grade IV 50, Grade V 13 pts) </li></ul><ul><li>Mean f/u 11 years (1 month – 39.6 years) </li></ul><ul><li>3 pts with Grade V presented with AVM rupture </li></ul><ul><li>Annual incidence of rupture: 3.3% </li></ul><ul><li>Cumulative rupture rates for recently ruptured high grade AVMs </li></ul><ul><li>At 5 years: 21 – 58% </li></ul><ul><li>At 20 years: 42 – 81% </li></ul><ul><li>Cumulative rupture rates for unruptured high grade AVMs </li></ul><ul><li>At 5 years: 0 – 13% </li></ul><ul><li>At 20 years: 3 – 46% </li></ul><ul><li>Previous rupture -> highly predictive of subsequent ruptures (6% per year) </li></ul><ul><li>Subsequent ruptures associated with higher risk of morbidity and mortality. </li></ul>
  • 11. <ul><li>Retrospective cohort </li></ul><ul><li>73 consecutive patients – Grade IV (n=56) & V (n=17)AVMs </li></ul><ul><li>1997 – 2000 </li></ul><ul><li>No Tx in 55, Partial Tx in 7, Complete surgical Tx in 4 </li></ul><ul><li>14 pts – previous Tx, 59 pts no previous Tx </li></ul><ul><li>In total, 38 haemorrhages in 73 patients </li></ul><ul><li>Assumed AVM present since birth </li></ul><ul><li>Haemorrhage rate of 1.5% per year. </li></ul><ul><li>Indications for surgery: </li></ul><ul><li>Several previous haemorrhages with significant neurological deficit </li></ul>
  • 12. Chang SD et al. Multimodality treatment of giant intracranial arteriovenous malformations. Neurosurgery 53(1): 1-13, 2003 Preferable to focus on our results.
  • 13. Andrew S Davidson & Michael K Morgan. How safe is arteriovenous malformation surgery? A prospective, observational study of surgery as first-line treatment for brain arteriovenous malformations . Neurosurgery 66(3): 498 – 505, 2010 <ul><li>Prospective observational study </li></ul><ul><li>20 years </li></ul><ul><li>660 patients enrolled – SM Grade IV (n=7) & V (n=23) </li></ul><ul><li>10 pts with SM Grade V AVM were operated. </li></ul><ul><li>Risk of adverse outcome due to surgery for this group (SM Grade V) is 24-76 % with 95% confidence interval. </li></ul><ul><li>Presence of deep perforating arterial supply -> asociated increased risk of surgical morbidity. </li></ul>
  • 14. Conclusion

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