Factors Associated with Unfavorable Clinical Presentations in Patients with Ruptured BrainArteriovenous Malformations

Joseph H Garcia; Luis Carrete; W Caleb Rutledge; Kunal P Raygor; Ethan A Winkler; Matheus Prado Pereira; Jeffrey Nelson; Helen Kim; Daniel L Cooke; Steven W Hetts; Michael T Lawton; Adib A Abla

doi:10.1016/j.wneu.2023.06.135

Factors Associated with Unfavorable Clinical Presentations in Patients with Ruptured BrainArteriovenous Malformations

World Neurosurg. 2023 Oct:178:e72-e78. doi: 10.1016/j.wneu.2023.06.135. Epub 2023 Jul 6.

Affiliations

¹ Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
² Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA.
³ Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA.
⁴ Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
⁵ Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA. Electronic address: garciaj9@upmc.edu.

PMID: 37422187
DOI: 10.1016/j.wneu.2023.06.135

Abstract

Background: Rupture of brain arteriovenous malformations (bAVMs) carries potentially devastating consequences. For patients presenting with ruptured bAVMs, several clinical grading systems have been shown to predict long-term patient morbidity and may be taken into consideration when making clinical decisions. Unfortunately, use of these scoring systems is typically limited to their prognostic value and offer little to patients in therapeutic benefit. Tools are needed not only to predict prognosis for patients experiencing ruptured bAVMs but to gain insight into what characteristics predispose patients to poor long-term outcomes before they rupture. Our objective was to find clinical, morphologic, and demographic variables that correlate with unfavorable clinical grades on presentation in patients with ruptured bAVMs.

Methods: We retrospectively reviewed a cohort of patients with ruptured bAVMs. Linear regression models were used to test whether Glasgow Coma Scale (GCS) and Hunt-Hess scores on presentation(outcomes) were associated with patient and arteriovenous malformation (AVM) characteristics (predictors) individually.

Results: GCS and Hunt-Hess were assessed following bAVM rupture for 121 brain cases. The median age at rupture was 28.5 years, and 62 (51%) were female. Smoking history was associated with worse GCS; current and past smokers had GCS scores 1.33 points lower on average than nonsmokers (95% confidence interval [CI] -2.59 to -0.07, P = 0.039) and had worse Hunt-Hess scores (0.42, 95% CI 0.07-0.77, P = 0.019). Associated aneurysms were associated with worse GCS (-1.60, 95% CI -3.16 to -0.05, P = 0.043) and trended towards worse Hunt-Hess scores (0.42 points, 95% CI -0.01 to 0.86, P = 0.057).

Conclusions: Patient smoking status and presence of an AVM associated aneurysm were shown to have modest correlations with unfavorable clinical grades (Hunt-Hess, GCS) on presentation, with unfavorable clinical grades being associated with long-term patient prognosis following bAVM rupture. Further investigation using AVM-specific grading scales and external data are needed to determine the utility of these and other variables in clinical practice for patients with bAVM.

Keywords: Aneurysm; Arteriovenous malformation; Cerebrovascular; Critical care; Prognosis; Prognostication; Smoking; Tobacco.