Clinical Neurology and Neurosurgery 138 (2015) 137–142 Contents lists available at ScienceDirect Clinical Neurology and Neurosurgery jo ur nal home p age: www.elsevier.com/locate/clineuro Ruptured cerebral arteriovenous malformations: Outcomes analysis after microsurgery Rabih Aboukaïs a,∗ , Paulo Marinho a , Marc Baroncini a , Philippe Bourgeois a , Xavier Leclerc b , Matthieu Vinchon a , Jean-Paul Lejeune a a Department of Neurosurgery, Lille University Hospital, France b Department of Neuroradiology, Lille University Hospital, France a r t i c l e i n f o Article history: Received 24 January 2015 Received in revised form 20 August 2015 Accepted 21 August 2015 Available online 28 August 2015 Keywords: AVM Aneurysm Nidus Remnant Outcome a b s t r a c t Objective: Our study aimed to evaluate the functional outcome and the risk of postoperative remnant in patients with rAVM after microsurgical treatment. Materials and methods: This is a retrospective of 139 consecutive patients operated for a rAVM between 2002 and 2012 in our institution. The age at diagnosis and the WFNS score were recorded for each patient before treatment. All patients were re-evaluated 3 months after treatment using mRS scale. Conventional angiography was performed in the first 2 postoperative weeks and then a year later to detect any remnant or recurrence. Results: The mean age at diagnosis was 30.8 years (range 4–69 SD: ±5) and 44 patients had an age at diag- nosis <18 yo. The mRS score 3 months after treatment was ≤2 in 104 patients (83%). Predictive factors of good functional outcome were age at diagnosis <25 yo, initial WFNS score ≤ 2, SPM grade ≤ 2 and absence of acute hydrocephalus (p < 0.05). Complete obliteration was obtained in 123 patients (89.5%) after the first microsurgical treatment. Early postoperative conventional angiography revealed a rAVM remnant in 16 patients (10.5%). Late conventional angiography showed a recurrence in 6 patients (4.5%). All of them were <18 yo. Predictive factors of postoperative rAVM remnant were an initial WFNS score > 2, SPM grade > 2 and preoperative evaluation limited only to CT angiography in emergency situation (p < 0.05). Conclusion: Functional outcome after microsurgical treatment was good in 83% of patients with rAVM. Good results were also recorded in 28% of patients with poor initial neurological status and severe intra- cerebral hemorrhage, which required immediate surgery. In case of remnant, a further treatment should be decided in a true multidisciplinary discussion to protect the patient from any rebleeding. © 2015 Elsevier B.V. All rights reserved. 1. Introduction Ruptured cerebral arteriovenous malformation (rAVM) is fre- quently managed by the neurosurgeons, particularly in emergency situation. The risk of hemorrhage for unruptured AVM is estimated between 1% and 4% per year according to different authors [11,20]. The history of previous hemorrhage is the main predictive factor of rupture [20]. Some authors reported a higher risk when unique deep venous drainage and/or associated aneurysm are present [11,20]. However, the preliminary findings of ARUBA study sup- port the conservative treatment [27] in patients with unruptured AVM but more delay for evaluation and data analysis is required [3,28]. Concerning rAVM, treatment is mandatory, to preserve vital ∗ Corresponding author at: Department of Neurosurgery, Lille University Hospital, rue E. Laine, 59037 Lille Cedex, France. E-mail address: rabihdoc@hotmail.com (R. Aboukaïs). and functional outcome of patients, and to protect them from a new hemorrhage. Microsurgery remains the main treatment of rAVM, however, endovascular management and radiosurgery should be discussed in some cases as adjuvant therapeutic tools or as unique treatment. For example, previous coiling of associated ruptured aneurysm is sometimes required before microsurgical resection of rAVM [38], or a further treatment by radiosurgery can be per- formed in case of postoperative rAVM remnant [39]. Nevertheless, microsurgery allows the immediate evacuation of intracerebral hematoma and the resection of the rAVM at the same time. Micro- surgical resection also has limitations such as the size of the rAVM or the location in deep or eloquent area. In these cases, the surgical procedure can only evacuate the intracerebral hematoma with- out attempting to cure the rAVM, which can be treated later using endovascular treatment or radiosurgery. Our study aimed to evaluate the functional outcome and the risk of postoperative remnant in patients with rAVM after microsurgical treatment. http://dx.doi.org/10.1016/j.clineuro.2015.08.017 0303-8467/© 2015 Elsevier B.V. All rights reserved.