Long-Term Outcomes of Elderly Brain Arteriovenous Malformations After Different Management Modalities: A Multicenter Retrospective Study

 You'll have to ask your doctor what elderly means because elderly are not suggested to get their AVMs fixed.

Long-Term Outcomes of Elderly Brain Arteriovenous Malformations After Different Management Modalities: A Multicenter Retrospective Study

Yu Chen¹, Debin Yan¹, Zhipeng Li¹, Li Ma¹, Yahui Zhao¹, Hao Wang¹, Xun Ye^1,2, Xiangyu Meng³, Hengwei Jin³, Youxiang Li³, Dezhi Gao⁴, Shibin Sun⁴, Ali Liu⁴, Shuo Wang¹, Xiaolin Chen^1* and Yuanli Zhao^1,2*

• ¹Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
• ²Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
• ³Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
• ⁴Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

Background: More and more elderly patients are being diagnosed with arteriovenous malformation (AVM) in this global aging society, while the treatment strategy remains controversial among these aging population. This study aimed to clarify the long-term outcomes of elderly AVMs after different management modalities.

Methods: The authors retrospectively reviewed 71 elderly AVMs (>60 years) in two tertiary neurosurgery centers between 2011 and 2019. Patients were divided into four groups: conservation, microsurgery, embolization, and stereotactic radiosurgery (SRS). The perioperative complications, short-term and long-term neurological outcomes, obliteration rates, annualized rupture risk, and mortality rates were compared among different management modalities in the ruptured and unruptured subgroups. Kaplan-Meier survival analysis was employed to compare the death-free survival rates among different management modalities. Logistic regression analyses were conducted to calculate the odds ratios (ORs) and 95% confidence intervals (CI) for predictors of long-term unfavorable outcomes (mRS > 2).

Results: A total of 71 elderly AVMs were followed up for an average of 4.2 ± 2.3 years. Fifty-four (76.1%) presented with hemorrhage, and the preoperative annualized rupture risk was 9.4%. Among these patients, 21 cases (29.6%) received conservative treatment, 30 (42.3%) underwent microsurgical resection, 13 (18.3%) received embolization, and 7 (9.9%) underwent SRS. In the prognostic comparison, the short-term and long-term neurological outcomes were similar between conservation and intervention both in the ruptured and unruptured subgroups (ruptured: p = 0.096, p = 0.904, respectively; unruptured: p = 0.568, p = 0.306, respectively). In the ruptured subgroup, the intervention cannot reduce long-term mortality (p = 0.654) despite the significant reduction of subsequent hemorrhage than conservation (p = 0.014), and the main cause of death in the intervention group was treatment-related complications (five of seven, 71.4%). In the logistic regression analysis, higher admission mRS score (OR 3.070, 95% CI 1.559–6.043, p = 0.001) was the independent predictor of long-term unfavorable outcomes (mRS>2) in the intervention group, while complete obliteration (OR 0.146, 95% CI 0.026–0.828, p = 0.030) was the protective factor.

Conclusions: The long-term outcomes of elderly AVMs after different management modalities were similar. Intervention for unruptured elderly AVMs was not recommended. For those ruptured, we should carefully weigh the risk of subsequent hemorrhage and treatment-related complications. Besides, complete obliteration should be pursued once the intervention was initiated.

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT04136860

Introduction

Brain arteriovenous malformations (AVMs) were described as cerebrovascular abnormalities with fistulous connections between arteries and veins without normal intervening capillary beds (Crawford et al., 1986; Solomon and Connolly, 2017; Goldberg et al., 2018). Most AVMs were diagnosed in the fourth and fifth decade of life (Perret and Nishioka, 1966), and elderly AVMs were relatively uncommon in clinical practice. Over the past three decades, neurosurgeons have not yet reached a consensus on whether or not to intervene in these patients. Initially, several studies suggested that the risk of rupture decreases as a person reaches middle age, and these lesions are relatively benign in elderly patients (Luessenhop and Rosa, 1984; Heros and Tu, 1987). However, Harbaugh et al. suggested the opposite (Harbaugh and Harbaugh, 1994). Several subsequent studies reported that 35.7–65.6% of elderly AVMs presented with hemorrhage, and they recommended microsurgical resection or stereotactic radiosurgical surgery (SRS) for carefully selected patients (Hashimoto et al., 2004; Nagata et al., 2006; Pabaney et al., 2016; Burkhardt et al., 2018; Chen et al., 2018). However, the previous studies only included a single treatment strategy for analysis and did not compare the long-term outcomes of different management modalities.

As life expectancy continues to increase in this global aging society, more elderly AVMs are being diagnosed. We must clarify the long-term outcomes of different management modalities for these patients. The present study retrospectively reviewed 71 elderly AVMs from our multi-center retrospective database of 2861 AVMs to specify the natural history and long-term outcomes after different management modalities.

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