Utilidad de las Escalas de Gradación en el Tratamiento Quirúrgico de Malformaciones Arteriovenosas Cerebrales / Usefulness of the Gradation Scales in the Surgical Treatment of Cerebral Arteriovenous Malformations

Introducción: Las malformaciones arteriovenosas (MAVs) cerebrales comprenden una compleja patología responsable de hasta el 38% de las hemorragias en pacientes de entre 15-45 años, acarreando cada episodio de sangrado un 25-50% de morbilidad y un 10-20% de mortalidad. La decisión terapéutica en un paciente con una MAV debe tener en cuenta la comparación entre los riesgos propios de la intervención y los de la historia natural de esta enfermedad. Objetivo: Evaluar la utilidad de predecir riesgo quirúrgico de diferentes escalas de gradación de MAV cerebrales según nuestra experiencia en una serie de casos. Material y Métodos: Se realizó un análisis bibliográfico de escalas de gradación de riesgo quirúrgico de MAV cerebrales utilizando como motor de búsqueda Pubmed incluyendo como palabras clave "malformación arteriovenosa cerebral" y "escala de gradación" (brain arteriovenous and malformation grading scale). Se analizaron de forma retrospectiva aquellos pacientes intervenidos quirúrgicamente por MAV en este hospital público, se las clasificó acorde a las escalas analizadas y se compararon los resultados obtenidos con los previstos en ellas. Resultados: Se analizaron 90 pacientes intervenidos quirúrgicamente por MAV, sin tratamiento coadyuvante. De forma retrospectiva se los agrupó acorde a las escalas de Spetzler Martin (SM), Spetzler-Ponce (SP) y suplementaria de Lawton. Las MAV grado 3 se subclasificaron según las escalas de Lawton y de de Oliveira. Considerando buenos resultados aquellos con Rankin modificado (mRs) igual o menor a 2. Con un rango de seguimiento de 12 a 48 meses, encontramos buenos resultados en el 100% de MAV SM grado 1, 91.7% de las grado 2, 80% en grado 3 y 42.9% en grado 4. Utilizando la escala SP, 93.7% de buenos resultados en tipo A, 80% en tipo B y 42.9% en tipo C. Subclasifican-do las MAV SM 3 acorde a las escalas de de Oliveira y Lawton, 84% de buenos resultados en el tipo 3A, 71.3% en las 3B, 92% en MAV tipo 3-, 72.1% en el tipo 3+, 60% en tipo 3. Utilizando la escala suplementaria de Lawton combinada con SM, buen resultado en 100% grados II y III, 85,7% grado IV, 87,6 grado V, 80% grado VI, 75% grado VII y 66,6% grado VIII. Conclusión: Reafirmamos en esta serie, la utilidad de estimar riesgo quirúrgico con las escalas SM, SP, y la subclasificación de las MAV grado 3 propuesta por Lawton. Y principalmente el utilizar la escala suplementaria de Lawton-Young al considerar el tratamiento quirúrgico de los pacientes con MAV que sangraron.

Introduction: Brain arteriovenous malformations (AVM) are a complex disease responsible for up to 38% of hemorrhages in patients between 15-45 years old, carrying every bleeding episode a 25-50% risk of morbidity and a 10-20% of mortality. The therapeutic decision in a patient with an AVM needs to consider both the risks of the intervention and the risks of the natural evolution of the disease. Objective: To assess the effectiveness of different AVM grading scales in predicting surgical risks according to our experience in a case series. Material and Method: a literature review of the AVM grading scales was made, through Pubmed including as key words "brain arteriovenous malformations" and "grading scale". A retrospective analysis was made of patients with AVM who were operated in our institution, they were classified according to the scales and their results were compared. Results: 90 patients were operated in our institution with AVM. Retrospectively, they were classified according to the Spetzler-Martin (SM), Spetzler-Ponce (SP), Lawton supplementary, and the sub-classifications in AVM grade 3, from Lawton and de Oliveira. Good outcome were considered when modified Rankin Scale (mRs) was equal or less than 2. The follow-up ranged from 12-48 months, having good outcome in 100% of AVM SM grade I, 91,7% grade II, 80% in grade III and 42,9% in grade IV. Using the SP scale, 93,7% of good outcome in grade A, 80% in grade B and 42,9% in grade C. In the sub-classification of AVM SM 3, we found 84% of good outcome in type 3A de Oliveira and 71,3% in type 3B. According to the Lawton scale, good outcome were found in 92% in type 3-, 72,1% in type 3+ and 60% in type 3. Using Lawton supplementary scale combined with SM, there were 100% of good outcome in grades II and III, 85,7% in grade IV, 87,6% in grade V, 80% in grade VI, 75% in grade VII, 66,6% in grade VIII. Conclusion: In our series, we reaffirm the effectiveness to predict surgical risk of the following scales: SM, SP and the Lawton's sub-classification of AVM grade 3. Specially, the use of the supplementary Lawton-Young scale in the surgical treatment of bleeding AVMs.

Analysis of clinical use Supplementary Spetzler-Martin grading system for brain arteriovenous malforma-tions / 中国神经精神疾病杂志

Objective We evaluate if supplementary grading system can refine patient selection and accurately predict neurological outcome in BAVM. Methods We retrospectively study 221 BAVM patients who were treated micro?surgically by our hospital. The score of pre and post operation mRS and relative clinical, radiology data were collected. Two different logistic models (Spetzler-Martin, Supplementary Spetzler-Martin grading model) were constructed to com?pare the area under ROC. Results Some factors are significant different between worse outcome patients and good out?come patients:Non-hemorrhagic presentations prior surgery, AVM bigger than 3cm, diffuse shape of AVM and the elder patients. Predictive accuracy was higher for the supplementary model (ROC area, 0.91), than the Spetzler-Martin model (ROC area, 0.774). So the predictive accuracy of supplementary model was significantly better than that of the Spet?zler-Martin model (P=0.0362). Conclusions Supplementary Spetzler-Martin model can improve preoperative risk pre?diction and subgroup the patients more efficiently. When the score less than 5(including 5) in supplementary Spet?zler-Martin patients seem to have lower risk relative to surgery.

The Spetzler-Martin Grading System and Management of Patients with Intracranial Arteriovenous Malformation in a Tertiary Referral Hospital

Introduction:An arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. The Spetzler-Martin grading system has been widely accepted worldwide to estimate the pretreatment risks and predict the outcome of patients with intracranial AVM. In Malaysia, we still do not have the baseline data of this grading system. Methods: A total of 33 patients from a tertiary referral hospital diagnosed with intracranial AVM based on neuroimaging findings over a 4-year period were studied. Medical records were traced and neuroimaging findings were analysed. The AVMs were graded according to the Spetzler-Martin grading system and Fisher's exact test was used to assess statistical difference between the grades of the AVM and management plan for the patients. Results: Four patients were graded as Grade 1, 9 patients as Grade II, 10 patients as Grade III, 6 patients as Grade IV and 4 patients as grade V.Ten patients were treated conservatively; six patients underwent surgery and embolisationrespectively. Statistically significant difference (p=0.016) was found between the Spetzler-Martin grading system and the management of intracranial AVMs. Conclusion: The management decision was not made based on the grading of the AVMs. It is recommended that all AVM patients be routinely graded according to this system prior to treatment