Tag: modified Rankin Scale

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Prospective untreated outcomes in patients with cerebral cavernous malformation

J Neurosurg 144:1344–1352, 2026

This prospective cohort study quantifies long-term functional outcomes in 332 untreated patients with cerebral cavernous malformation (CCM), using modified Rankin Scale (mRS) scores to evaluate disability over a mean 6.6-year follow-up. It reports incidence of symptomatic hemorrhage (SH), temporal patterns of recovery after a first SH, and external validation of published predictive nomograms.

Key findings identify brainstem location, a history of self-reported psychiatric disorder, and two or more SHs as independent predictors of long-term disability; most patients improved within one year after a first hemorrhage, and ten-year disability risk for nonbrainstem CCM was under 8%.

Objective Elucidate long-term morbidity and disability risk in adults with untreated cerebral cavernous malformation (CCM).

Methods Prospectively followed registry cohort; functional outcome tracked using mRS, with disability defined as mRS ≥ 3; time-to-disability analyzed via Kaplan–Meier and risk factors via Cox models; previously published morbidity nomograms were externally validated.

Cohort 332 patients (58.4% female; mean age 44.5); 19.8% familial CCM; 28.0% brainstem location; 38.3% presented with symptomatic hemorrhage (SH).

Recovery after first SH Among patients with SH who had no further SH and no surgery (n=48), disability (mRS ≥ 3) was 27.1% at diagnosis, improving to 6.2% at 1 year and 4.7% at 5 years, with most improvement in year 1.

Hemorrhage burden Over mean 6.6 years, 31.0% had ≥1 prospective SH and 14.5% had multiple prospective SHs; disability rose sharply with each SH (mRS ≥ 3: 2.3% with 0 SH up to 100% after 5 SHs in untreated follow-up).

Location risk Brainstem CCM carried substantially higher disability risk (18.8% at 5 years; 35.4% at 10 years) versus nonbrainstem locations (4.1% at 5 years; 7.5% at 10 years).

Predictors Multivariate predictors of disability included brainstem location, self-reported psychiatric disorder, and ≥2 SHs.

Nomogram validation Prior nomograms showed high specificity but limited sensitivity; AUC 0.687 for predicting mRS ≥ 2 and 0.783 for predicting mRS ≥ 3.

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Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system

J Neurosurg 136:125–133, 2022

Supplemented Spetzler-Martin grading (Supp-SM), which is the combination of Spetzler-Martin and Lawton-Young grades, was validated as being more accurate than stand-alone Spetzler-Martin grading, but an operability cutoff was not established. In this study, the authors surgically treated intermediate-grade AVMs to provide prognostic factors for neurological outcomes and to define AVMs at the boundary of operability.

METHODS Surgically treated Supp-SM intermediate-grade (5, 6, and 7) AVMs were analyzed from 2011 to 2018 at two medical centers. Worsened neurological outcomes were defined as increased modified Rankin Scale (mRS) scores on postoperative examinations. A second analysis of 2000–2011 data for Supp-SM grade 6 and 7 AVMs was performed to determine the subtypes with improved or unchanged outcomes. Patients were separated into three groups based on nidus size (S1: < 3 cm, S2: 3–6 cm, S3: > 6 cm) and age (A1: < 20 years, A2: 20–40 years, A3: > 40 years), followed by any combination of the combined supplemented grade: low risk (S1A1, S1A2, S2A1), intermediate risk (S2A2, S1A3, S3A1, or high risk (S3A3, S3A2, S2A3).

RESULTS Two hundred forty-six patients had intermediate Supp-SM grade AVMs. Of these patients, 102 had Supp-SM grade 5 (41.5%), 99 had Supp-SM grade 6 (40.2%), and 45 had Supp-SM grade 7 (18.3%). Significant differences in the proportions of patients with worse mRS scores at follow-up were found between the groups, with 24.5% (25/102) of patients in Supp-SM grade 5, 29.3% (29/99) in Supp-SM grade 6, and 57.8% (26/45) in Supp-SM grade 7 (p < 0.001). Patients with Supp-SM grade 7 AVMs had significantly increased odds of worse postoperative mRS scores (p < 0.001; OR 3.7, 95% CI 1.9–7.3). In the expanded cohort of 349 Supp-SM grade 6 AVM patients, a significantly higher proportion of older patients with larger Supp-SM grade 6 AVMs (grade 6+, 38.6%) had neurological deterioration than the others with Supp-SM grade 6 AVMs (22.9%, p = 0.02). Conversely, in an expanded cohort of 197 Supp-SM grade 7 AVM patients, a significantly lower proportion of younger patients with smaller Supp-SM grade 7 AVMs (grade 7–, 19%) had neurological deterioration than the others with Supp-SM grade 7 AVMs (44.9%, p = 0.01).

CONCLUSIONS Patients with Supp-SM grade 7 AVMs are at increased risk of worse postoperative neurological outcomes, making Supp-SM grade 6 an appropriate operability cutoff. However, young patients with small niduses in the low-risk Supp-SM grade 7 group (grade 7−) have favorable postoperative outcomes. Outcomes in Supp-SM grade 7 patients did not improve with surgeon experience, indicating that the operability boundary is a hard limit reflecting the complexity of high-grade AVMs.

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Woven Endobridge Embolization Versus Microsurgical Clipping for Unruptured Anterior Circulation Aneurysms

Neurosurgery 88:779–784, 2021

Intrasaccular flow-disruption represents a new paradigmin endovascular treatment of wide-necked bifurcation aneurysms.

OBJECTIVE: To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment.

METHODS: A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion.

RESULTS: The technical success rates were 83% forWEB and 100% for clipping. Procedure related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P<.01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01).

CONCLUSION: Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient’s preferences.

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The Application of the Novel Grading Scale (Lawton-Young Grading System) to Predict the Outcome of Brain Arteriovenous Malformation

Neurosurgery 84:529–536, 2019

A supplementary grading scale (Supplemented Spetzler-Martin grade, Supp-SM) was introduced in 2010 as a refinement of the SM system to improve preoperative risk prediction of brain arteriovenous malformations (AVMs).

OBJECTIVE: To determine the ability to predict surgical outcomes using the Supp-SM grading scale.

METHODS: This retrospective study was conducted on 200 patients admitted to the Helsinki University Hospital between 2000 and 2014. The validity of the Supp-SM and SM grading systems was compared using the area under the receiver operating characteristic (AUROC) curves, with respect to the change between preoperative and early (3-4 mo) as well as final postoperative modified Rankin Scale (mRS) scores.

RESULTS: The performance of the Supp-SM was superior to that of the SM grading scale in the early follow-up (3-4 mo): AUROC = 0.57 (95% confidence interval [CI]: 0.49-0.65) for SM and AUROC = 0.67 (95% CI: 0.60-0.75) for Supp-SM. The Supp-SM performance continued improving over SM at the late follow-up: AUROC=0.63 (95% CI: 0.55-0.71) for SM and AUROC = 0.70 (95% CI: 0.62-0.77) for Supp-SM. The perforating artery supply, which is not part of either grading system, plays an important role in the early follow-up outcome (P = .008; odds ratio: 2.95; 95% CI: 1.32-6.55) and in the late follow-up outcome (P < .001; odds ratio: 5.89; 95% CI: 2.49-13.91).

CONCLUSION: The Supp-SM grading system improves the outcome prediction accuracy and is a feasible alternative to the SMS, even for series with higher proportion of high-grade AVMs. However, perforators play important role on the outcome.

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Predictive factors for recurrence and clinical outcomes in patients with chronic subdural hematoma

J Neurosurg 127:1117–1125, 2017

Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in elderly patients. Many studies have suggested various factors that may be associated with the recurrence of CSDH. However, the results are inconsistent. The purpose of this study was to determine the associations among patient factors, recurrence, and clinical outcomes of CSDH after burr hole surgery performed during an 11-year period at twin hospitals.

METHODS Kaplan-Meier analysis was performed to evaluate the risk factors for CSDH recurrence. Univariate and multivariate Cox proportional hazards regression analyses were used to calculate hazard ratios with 95% CIs for CSDH recurrence based on many variables. One-way repeated-measures ANOVA was used to assess the differences in the mean modified Rankin Scale score between categories for each risk factor during each admission and at the last follow-up.

RESULTS This study was a retrospective analysis of 756 consecutive patients with CSDH who underwent burr hole surgery at the Hanyang University Medical Center (Seoul and Guri) between January 1, 2004, and December 31, 2014. During the 6-month follow-up, 104 patients (13.8%) with recurrence after surgery for CSDH were identified. Independent risk factors for recurrence were as follows: age > 75 years (HR 1.72, 95% CI 1.03–2.88; p = 0.039), obesity (body mass index ≥ 25.0 kg/m2), and a bilateral operation.

CONCLUSIONS This study determined the risk factors for recurrence of CSDH and their effects on outcomes. Further studies are needed to account for these observations and to determine their underlying mechanisms.

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