Retrospective study of long-term outcome after brain arteriovenous malformation rupture: the RAP score

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OBJECTIVE

The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome.

METHODS

The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality.

RESULTS

One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1–13.7, p < 10−3), hematoma volume (OR 1.8, 95% CI 1.2–2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66–21, p < 10−3) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8–0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85–0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6–87) and 90.8% (95% CI 81.9–96.2), respectively.

CONCLUSIONS

The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.

ABBREVIATIONS AUC = area under the ROC curve; BAVM = brain arteriovenous malformation; BP = blood pressure; EVD = external ventricular drain; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; RAP = ruptured AVM prognostic; ROC = receiver operating characteristic.

Article Information

Correspondence Frédéric Clarençon, Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, Paris 75013, France. email: fredclare5@gmail.com.

INCLUDE WHEN CITING Published online January 20, 2017; DOI: 10.3171/2016.9.JNS161431.

Drs. Degos and Clarençon contributed equally to this work.

Disclosures Dr. Clarençon is a consultant for Medtronic and Codman Neurovascular. Dr. Sourour is a consultant for Medtronic and Microvention.

© AANS, except where prohibited by US copyright law.

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    Recruitment flowchart.

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    Distribution of RAP score and comparison with the ICH score according to the AUC. A: Distribution of RAP score values in the study population (n = number of hemorrhagic events). B: Observed and best-fit curve of the percentage of poor outcome for each value of the RAP score. C: Comparison of AUCs for RAP and ICH scores for predicting poor long-term outcome. D: Comparison of AUCs for RAP and ICH scores for predicting inpatient mortality. Figure is available in color online only.

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