Outcome of Microsurgery for Arteriovenous Malformations in a Resource-Restricted Environment: Single-Surgeon Series from Vietnam Walter C. Jean 1,3 , Trong Huynh 6,4 , Alexander X. Tai 2 , Daniel R. Felbaum 2,3 , Hasan R. Syed 3,5 , Hung M. Ngo 6 - BACKGROUND: The health care expenditure in Vietnam is equivalent to 1% of that in the United States. For most patients with brain arteriovenous malformations (AVM), surgery is the only available treatment modality. This study reports on the outcomes on AVM microsurgery in this resource-restricted environment. - METHODS: This is a prospectively collected, retro- spectively analyzed case series of consecutive patients who underwent surgical resection of AVM by a single surgeon in Vietnam. All surgeries were performed in a 3- year period in Hanoi. The primary endpoints were obliter- ation of the AVM and surgical morbidity (modified Rankin Scale [mRS] > 1). - RESULTS: There were 86 patients and 62% presented with hemorrhage. Only 2 patients had preoperative embolization, and 47 patients (54%) had preoperative digital subtraction angiography. All patients underwent microsurgical resection of their AVM. Excluding the 4 patients who died, the AVM obliteration rate was 98%. The mean follow-up was 20.1 months. Before surgery, 36% of patients had at least some disability (mRS > 1). Postoperatively, this was reduced to 10% (McNemar P [ 0.007). For the overall cohort, neurologic status was improved from initial encounter to final assess- ment (P [ 0.001). Because of resource restrictions, some patients with hemorrhage experienced delays in treatment. There was no difference in outcome between patients who were admitted before or after 24 hours post ictus (P [ 0.6). The days spent waiting for surgery did not correlate with final mRS in univariate regression (R 2 [ 0.01). - CONCLUSIONS: Notwithstanding the limitation in health care resources in Vietnam, surgery for AVMs was suc- cessful in eliminating the malformation, with obliteration rates and morbidity comparable with international standards. INTRODUCTION S urgical treatment for cerebral arteriovenous malformation (AVM) is expensive throughout the world. This topic was studied in 127 German patients whose average hospital stay was 15.4 days. 1 The average cost of microsurgical treatment was V10,814. In the United Kingdom, the inpatient cost over 3 years for each surgically treated AVM patient was £11,000, 2 while in the United States, the average cost per AVM surgery was $49,000, escalating to $78,000 if supplemented with preoperative embolization. 3 Endovascular treatment is not affordable in low-to-middle in- come countries such as the Socialist Republic of Vietnam. The gross domestic product of the country was 224 billion in 2017, and the health care expenditure per capita is 1/30 that of the United Kingdom, 1/36 of Germany, and 1/100 of the United States. 4 Under this financial backdrop, patients with both unruptured and ruptured AVMs are treated with microsurgery in centralized specialty hospitals in major urban centers of Vietnam. The current study investigates the outcomes of a single surgeon’s patient cohort from Viet Duc Hospital in Hanoi, Vietnam. We seek to document the surgical outcomes in these resource- intense neurosurgical patients who were treated in an environ- ment with severe resource constraints. Key words - Arteriovenous malformation - Intracerebral hemorrhage - Modified Rankin Scale - Vietnam Abbreviations and Acronyms AVM: Arteriovenous malformation CTA: Computed tomography angiogram DSA: Digital subtraction angiography GCS: Glasgow Coma Scale ICU: Intensive care unit mRS: Modified Rankin Scale SM: Spetzler-Martin From the 1 Department of Neurosurgery, George Washington University, Washington, D.C.; 2 Department of Neurosurgery, Georgetown University Hospital, Washington, D.C.; 3 Global Brainsurgery Initiative, Washington, D.C.; 4 Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey; and 5 Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA; and 6 Department of Neurosurgery, Viet Duc Hospital, Hanoi, Vietnam To whom correspondence should be addressed: Walter C. Jean, M.D. [E-mail: wjean@mfa.gwu.edu] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.08.256 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY -: e1-e10, - 2019 www.journals.elsevier.com/world-neurosurgery e1 Original Article