{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T21:53:00Z","timestamp":1768341180652,"version":"3.49.0"},"reference-count":29,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,10,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The natural history of ruptured high Spetzler-Martin grade IV and V brain arteriovenous malformations (bAVMs) is underreported given the scarcity of this pathology, and decision-making for patients with bAVMs remains unclarified. In this study, the authors sought to shed light on this topic.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>Patients harboring ruptured high-grade bAVMs were identified from an institutional database spanning from 1990 to 2020. The authors examined outcomes of annual hemorrhagic risk in natural history and after treatment, follow-up hemorrhage rate, bAVM obliteration, follow-up modified Rankin Scale (mRS) score &gt; 2, worsened mRS score, and mortality.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>After reviewing the charts of 1066 patients without hereditary hemorrhagic telangiectasia, 84 patients with ruptured high-grade bAVMs were included in the study for analysis. For cortical bAVMs, the annual risk of hemorrhage during natural history was 2.68%. Surgery decreased the risk to 0.74%, while radiosurgery increased the risk to 5.35%, and embolization only increased the risk to 16.96%. For deep-seated high-grade bAVMs, the annual risk of hemorrhage during natural history was 8.37%. Radiosurgery decreased the risk to 3.11%, surgery decreased the risk to 5.25%, and embolization only increased the risk to 22.33%. Poisson regression analysis demonstrated that embolization only increased the risk of hemorrhage in cortical bAVMs (rate ratio 4.745, 95% CI 1.365\u201312.819; p = 0.005) and deep-seated bAVMs (rate ratio 6.290, 95% CI 0.997\u201321.932; p = 0.013). Logistic regression analysis showed that surgery (OR 52.000, 95% CI 8.083\u20131046.127; p = 0.004) and radiosurgery (OR 11.142, 95% CI 1.804\u2013217.650; p = 0.029) were predictors of obliteration in cortical and deep-seated bAVMs, respectively. The proportions of patients experiencing a worsened mRS score, a follow-up mRS score &gt; 2, and mortality were similar between conservative and treatment groups.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>The natural history of cortical ruptured high-grade bAVMs bears a risk similar to that of incidental bAVMs, whereas deep-seated ruptured high-grade bAVMs have an increased risk of hemorrhage. With extremely prudent patient selection, surgery might be a viable option for cortical bAVMs to obliterate the bAVM and reduce hemorrhagic risk, while preserving functional status. Radiosurgery might be beneficial to lower hemorrhagic risk in deep-seated bAVMs. Embolization as a single modality should be avoided as it provides no benefit to reduce hemorrhagic risk.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2024.6.jns241075","type":"journal-article","created":{"date-parts":[[2024,10,19]],"date-time":"2024-10-19T01:32:25Z","timestamp":1729301545000},"page":"1-9","source":"Crossref","is-referenced-by-count":1,"title":["Natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations"],"prefix":"10.3171","author":[{"given":"Shahab Aldin","family":"Sattari","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wuyang","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Feghali","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Albert","family":"Antar","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alice","family":"Hung","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Risheng","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rafael J.","family":"Tamargo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Judy","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"19","key":"b1","series-title":"N Engl J Med","first-page":"1859","article-title":"Arteriovenous malformations of the brain","volume":"376","author":"Solomon RA","year":"2017","unstructured":"Solomon RA, Connolly ES Jr. Arteriovenous malformations of the brain. N Engl J Med. 2017;376(19):1859\u20131866."},{"key":"b2","series-title":"Nat Rev Dis Primers","first-page":"15008","article-title":"Brain arteriovenous malformations","volume":"1","author":"Lawton MT","year":"2015","unstructured":"Lawton MT, Rutledge WC, Kim H,  Brain arteriovenous malformations. Nat Rev Dis Primers. 2015;1:15008."},{"issue":"3","key":"b3","series-title":"J Neurosurg","first-page":"387","article-title":"The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment","volume":"73","author":"Ondra SL","year":"1990","unstructured":"Ondra SL, Troupp H, George ED, Schwab K. The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg. 1990;73(3):387\u2013391."},{"issue":"5","key":"b4","series-title":"Neurosurgery","first-page":"823","article-title":"Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients","volume":"63","author":"Hernesniemi JA","year":"2008","unstructured":"Hernesniemi JA, Dashti R, Juvela S, V\u00e4\u00e4rt K, Niemel\u00e4 M, Laakso A. Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery. 2008;63(5):823\u2013831."},{"issue":"1","key":"b5","series-title":"Stroke","first-page":"100","article-title":"The natural history and predictive features of hemorrhage from brain arteriovenous malformations","volume":"40","author":"da Costa L","year":"2009","unstructured":"da Costa L, Wallace MC, Ter Brugge KG, O\u2019Kelly C, Willinsky RA, Tymianski M. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke. 2009;40(1):100\u2013105."},{"issue":"1","key":"b6","series-title":"Neurosurgery","first-page":"27","article-title":"Microsurgery versus microsurgery with preoperative embolization for brain arteriovenous malformation treatment: a systematic review and meta-analysis","volume":"92","author":"Sattari SA","year":"2023","unstructured":"Sattari SA, Shahbandi A, Yang W, Feghali J, Xu R, Huang J. Microsurgery versus microsurgery with preoperative embolization for brain arteriovenous malformation treatment: a systematic review and meta-analysis. Neurosurgery. 2023;92(1):27\u201341."},{"issue":"6","key":"b7","series-title":"Stroke","first-page":"1458","article-title":"AHA Scientific Statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association","volume":"32","author":"Ogilvy CS","year":"2001","unstructured":"Ogilvy CS, Stieg PE, Awad I,  AHA Scientific Statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke. 2001;32(6):1458\u20131471."},{"issue":"8","key":"b8","series-title":"Stroke","first-page":"e200","article-title":"Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association\/American Stroke Association","volume":"48","author":"Derdeyn CP","year":"2017","unstructured":"Derdeyn CP, Zipfel GJ, Albuquerque FC,  Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association\/American Stroke Association. Stroke. 2017;48(8):e200\u2013e224."},{"issue":"4","key":"b9","series-title":"J Neurosurg","first-page":"476","article-title":"A proposed grading system for arteriovenous malformations","volume":"65","author":"Spetzler RF","year":"1986","unstructured":"Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476\u2013483."},{"issue":"3","key":"b10","series-title":"J Neurosurg","first-page":"842","article-title":"A 3-tier classification of cerebral arteriovenous malformations","volume":"114","author":"Spetzler RF","year":"2011","unstructured":"Spetzler RF, Ponce FA. A 3-tier classification of cerebral arteriovenous malformations. J Neurosurg. 2011;114(3):842\u2013849."},{"issue":"CN_suppl_1","key":"b11","series-title":"Neurosurgery","first-page":"24","article-title":"Contemporary management of high-grade brain arteriovenous malformations","volume":"65","author":"Ding D","year":"2018","unstructured":"Ding D, Ilyas A, Sheehan JP. Contemporary management of high-grade brain arteriovenous malformations. Neurosurgery. 2018;65(CN_suppl_1):24\u201333."},{"issue":"1","key":"b12","series-title":"J Neurosurg","first-page":"3","article-title":"Intention-to-treat analysis of Spetzler-Martin grades IV and V arteriovenous malformations: natural history and treatment paradigm","volume":"98","author":"Han PP","year":"2003","unstructured":"Han PP, Ponce FA, Spetzler RF. Intention-to-treat analysis of Spetzler-Martin grades IV and V arteriovenous malformations: natural history and treatment paradigm. J Neurosurg. 2003;98(1):3\u20137."},{"issue":"2","key":"b13","series-title":"Stroke","first-page":"325","article-title":"Hemorrhage rate in patients with Spetzler-Martin grades IV and V arteriovenous malformations: is treatment justified?","volume":"38","author":"Jayaraman MV","year":"2007","unstructured":"Jayaraman MV, Marcellus ML, Do HM,  Hemorrhage rate in patients with Spetzler-Martin grades IV and V arteriovenous malformations: is treatment justified? Stroke. 2007;38(2):325\u2013329."},{"issue":"2","key":"b14","series-title":"Neurosurgery","first-page":"372","article-title":"Risk of hemorrhage in patients with untreated Spetzler-Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients","volume":"68","author":"Laakso A","year":"2011","unstructured":"Laakso A, Dashti R, Juvela S, Isarakul P, Niemel\u00e4 M, Hernesniemi J. Risk of hemorrhage in patients with untreated Spetzler-Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients. Neurosurgery. 2011;68(2):372\u2013378."},{"issue":"1","key":"b15","series-title":"Neurosurgery","first-page":"1","article-title":"Multimodality treatment of giant intracranial arteriovenous malformations","volume":"53","author":"Chang SD","year":"2003","unstructured":"Chang SD, Marcellus ML, Marks MP, Levy RP, Do HM, Steinberg GK. Multimodality treatment of giant intracranial arteriovenous malformations. Neurosurgery. 2003;53(1):1\u201313."},{"issue":"1","key":"b16","series-title":"Neurosurg Focus","first-page":"E12","article-title":"Long-term outcomes of Spetzler-Martin grade IV and V arteriovenous malformations: a single-center experience","volume":"53","author":"Li N","year":"2022","unstructured":"Li N, Yan D, Li Z,  Long-term outcomes of Spetzler-Martin grade IV and V arteriovenous malformations: a single-center experience. Neurosurg Focus. 2022;53(1):E12."},{"issue":"2","key":"b17","series-title":"J Neurosurg","first-page":"498","article-title":"Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study","volume":"129","author":"Patibandla MR","year":"2018","unstructured":"Patibandla MR, Ding D, Kano H,  Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study. J Neurosurg. 2018;129(2):498\u2013507."},{"issue":"12","key":"b18","series-title":"J Neurol Neurosurg Psychiatry","first-page":"1044","article-title":"The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results","volume":"54","author":"Farrell B","year":"1991","unstructured":"Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry. 1991;54(12):1044\u20131054."},{"issue":"1","key":"b19","series-title":"Milbank Mem Fund Q","first-page":"69","article-title":"On the person years concept in epidemiology and demography","volume":"44","author":"Sheps MC","year":"1966","unstructured":"Sheps MC. On the person years concept in epidemiology and demography. Milbank Mem Fund Q. 1966;44(1):69\u201391."},{"issue":"9","key":"b20","series-title":"Stroke","first-page":"2430","article-title":"Racial\/ethnic differences in longitudinal risk of intracranial hemorrhage in brain arteriovenous malformation patients","volume":"38","author":"Kim H","year":"2007","unstructured":"Kim H, Sidney S, McCulloch CE,  Racial\/ethnic differences in longitudinal risk of intracranial hemorrhage in brain arteriovenous malformation patients. Stroke. 2007;38(9):2430\u20132437."},{"issue":"7","key":"b21","series-title":"Neurology","first-page":"590","article-title":"Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors","volume":"83","author":"Kim H","year":"2014","unstructured":"Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL. Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors. Neurology. 2014;83(7):590\u2013597."},{"issue":"6","key":"b22","series-title":"Stroke","first-page":"1384","article-title":"Risk of brain arteriovenous malformation hemorrhage before and after stereotactic radiosurgery","volume":"50","author":"Ding D","year":"2019","unstructured":"Ding D, Chen CJ, Starke RM,  Risk of brain arteriovenous malformation hemorrhage before and after stereotactic radiosurgery. Stroke. 2019;50(6):1384\u20131391."},{"issue":"2","key":"b23","series-title":"Neurosurgery","first-page":"343","article-title":"Systemic expression of matrix metalloproteinase-9 in patients with cerebral arteriovenous malformations","volume":"66","author":"Starke RM","year":"2010","unstructured":"Starke RM, Komotar RJ, Hwang BY,  Systemic expression of matrix metalloproteinase-9 in patients with cerebral arteriovenous malformations. Neurosurgery. 2010;66(2):343\u2013348."},{"issue":"3","key":"b24","series-title":"Neurosurgery","first-page":"663","article-title":"Hypoxia-inducible factor and vascular endothelial growth factor are expressed more frequently in embolized than in nonembolized cerebral arteriovenous malformations","volume":"55","author":"Sure U","year":"2004","unstructured":"Sure U, Battenberg E, Dempfle A, Tirakotai W, Bien S, Bertalanffy H. Hypoxia-inducible factor and vascular endothelial growth factor are expressed more frequently in embolized than in nonembolized cerebral arteriovenous malformations. Neurosurgery. 2004;55(3):663\u2013670."},{"issue":"1","key":"b25","series-title":"J Neurosurg","first-page":"1","article-title":"Spetzler-Martin grades IV and V arteriovenous malformations","volume":"98","author":"Heros RC","year":"2003","unstructured":"Heros RC. Spetzler-Martin grades IV and V arteriovenous malformations. J Neurosurg. 2003;98(1):1\u20132."},{"issue":"2","key":"b26","series-title":"J Neurosurg","first-page":"388","article-title":"Embolization of brain arteriovenous malformations with intent to cure: a systematic review","volume":"132","author":"Wu EM","year":"2019","unstructured":"Wu EM, El Ahmadieh TY, McDougall CM,  Embolization of brain arteriovenous malformations with intent to cure: a systematic review. J Neurosurg. 2019;132(2):388\u2013399."},{"key":"b27","series-title":"Neurosurgery","article-title":"Primary embolization of cerebral arteriovenous malformations with intention to cure: a systematic review of literature and meta-analysis","author":"Dabhi N","unstructured":"Dabhi N, Sokolowski J, Zanaty M, Kellogg RT, Park MS, Mastorakos P. Primary embolization of cerebral arteriovenous malformations with intention to cure: a systematic review of literature and meta-analysis. Neurosurgery. Published online June 6, 2024. doi:10.1227\/neu.0000000000003001"},{"issue":"3","key":"b28","series-title":"Neurosurgery","first-page":"510","article-title":"Microsurgery versus stereotactic radiosurgery for treatment of patients with brain arteriovenous malformation: a systematic review and meta-analysis","volume":"93","author":"Sattari SA","year":"2023","unstructured":"Sattari SA, Shahbandi A, Kim JE,  Microsurgery versus stereotactic radiosurgery for treatment of patients with brain arteriovenous malformation: a systematic review and meta-analysis. Neurosurgery. 2023;93(3):510\u2013523."},{"issue":"5","key":"b29","series-title":"Br J Neurosurg","first-page":"666","article-title":"Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations","volume":"28","author":"Ding D","year":"2014","unstructured":"Ding D, Yen CP, Starke RM, Xu Z, Sun X, Sheehan JP. Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations. Br J Neurosurg. 2014;28(5):666\u2013674."}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/aop\/article-10.3171-2024.6.JNS241075\/article-10.3171-2024.6.JNS241075.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/aop\/article-10.3171-2024.6.JNS241075\/article-10.3171-2024.6.JNS241075.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/aop\/article-10.3171-2024.6.JNS241075\/article-10.3171-2024.6.JNS241075.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,1]],"date-time":"2025-03-01T01:38:39Z","timestamp":1740793119000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/aop\/article-10.3171-2024.6.JNS241075\/article-10.3171-2024.6.JNS241075.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,10,1]]},"references-count":29,"URL":"https:\/\/doi.org\/10.3171\/2024.6.jns241075","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,10,1]]}}}