Accepted Manuscript

The AVICH-score: Potential implications for stroke center designations and patient
centered care

J. Scott Pannell, MD, Yasaman Alam, Alexander A. Khalessi, MD, MS, FAHA, FAANS

PII: S1878-8750(16)30527-7
DOI: 10.1016/j.wneu.2016.06.132
Reference: WNEU 4298

To appear in: World Neurosurgery

Received Date: 30 June 2016

Accepted Date: 30 June 2016

Please cite this article as: Pannell JS, Alam Y, Khalessi AA, The AVICH-score: Potential implications
for stroke center designations and patient centered care, World Neurosurgery (2016), doi: 10.1016/
j.wneu.2016.06.132.

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 ACCEPTED MANUSCRIPT

The AVICH-score: Potential implications for stroke center designations and patient centered care.

J. Scott Pannell MD1, Yasaman Alam1, and Alexander A. Khalessi, MD, MS, FAHA, FAANS1

1. University of California, San Diego

Corresponding Author:

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Alexander A. Khalessi, MD, MS, FAANS, FAHA
Associate Professor of Surgery and Neurosciences
Department of Neurosurgery

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University of California – San Diego
200 West Arbor Drive
San Diego, CA 92103

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Phone: 619-543-5540
Email: akhalessi@ucsd.edu

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Key Words: AVICH-score, ruptured AVM, and Hemorrhagic stroke.
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Introduction:
Drs. Neidert and colleagues propose a novel outcome AVM grading scale designed specifically
for predicting clinical outcomes in ICH due to ruptured AVM. Given the controversy surrounding
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treatment of AVMs following the ARUBA trial, the renewed focus on ruptured AVMs is of great interest
to the readership. The treatment of ruptured AVMs remains unquestioned. The AVICH-score combines
elements of the validated the ICH scale score originally designed to predict clinical outcomes in ICH and
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the validated Supplemented Spetzler-Martin grading scale designed to predict surgical outcomes in
AVMs. The AVICH-score proposed demonstrates superiority to previous AVM grading scales in outcomes
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prediction in the foundational cohort. Though the AVICH-score requires external validation, the authors
merit congratulations for this important first step in improving our ability to provide prognostic
information to these critically ill patients and their families in the setting of an acutely disabling or life
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threatening event.

Background:
As the authors’ demonstrate, hemorrhagic stroke outcomes range from neurologically intact to
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death. The trend for dichotomization of outcomes into functionally independent (mRS 0-2) and
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dependent status (mRS >3) adopted by the authors in the development of the AVICH-score stems from
developments in ischemic stroke care. Extension of the previously mentioned functional dichotomy to
hemorrhagic stroke is both practical and intuitive in the application of Comprehensive Stroke Center
outcomes measures. The most important determining factors in predicting hemorrhagic stroke
outcomes in AVM patients are location of the hemorrhage, size of the hematoma, neurologic status at
presentation, age of the patient, and amenability of the AVM to treatment.

The initial Spetzler-Martin grade focused on amenability of the AVM to treatment and surgical
treatment outcomes rather functional clinical outcomes in the setting of AVM rupture. As such, the
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Spetzler-Martin grade focused on the anatomic nature of the AVM rather than patient centered factors
such as patient age, presenting neurologic status, rupture status, or location and severity of
hemorrhage. Specifically, the Spetzler-Martin grading scale published in 1986 assigned one to three
points for AVM size, one point for involvement of eloquent cortex, and one point for deep venous
drainage for a total of five points. In their retrospective study, Spetzler and Martin retrospectively
applied their scoring scale to 100 AVM patients. Higher Spetzler-Martin grade demonstrated a direct

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correlation between post-operative neurologic deficit as well as an inverse correlation between
likelihood of surgical resection.1

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In 2010, Lawton et. al introduced the Supplemented Spetzler-Martin grading scale specifically to
predict surgical outcomes in ruptured AVMs. The Supplemented Spetzler-Martin grading scale also
included rupture status, age of the patient, and nidal architecture (diffuse verses focal). In the 300

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patients in Lawton’s 2010 study, the supplemental Spetzler-Martin grading scale demonstrated a
stronger correlation with surgical outcomes than the initial Spetzler-Martin grading scale (ROC 0.78 vs
0.66).2 The supplemented scale was validated in 2015 by Kim et. al in a cohort of 1009 AVM patients.3

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However, the supplemented Spetzler-Martin grading system was not specifically designed to predict
clinical outcome and did not account for presenting neurological status, which demonstrated strong
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correlation to clinical outcomes in the ICH scale score.

The ICH scale score proposed by Hemphill et. al in 2001 addressed aforementioned presenting
patient centered factors including presenting neurologic status (GCS). The ICH scale score assigns zero
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to two points for GCS, one point for volume greater than 30 cc, one point for intraventricular
hemorrhage, one point for infratentorial location, and one point for age greater than 80. The ICH scale
score demonstrated a strong direct correlation with morbidity and mortality. For example, an ICH scale
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core two has a 30-day mortality of 26%, while a score of five has a 100% 30-day mortality (P<0.005).4
Unfortunately, the ICH scale score was not intended for application to hemorrhagic stroke related to a
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ruptured AVM. As such, the ICH scale score does not included surgical factors related to AVM
treatment.
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Discussion:
As mentioned above, the proposed AVICH-score combines the both the anatomic considerations
related to AVM resection of the validated Supplemented Spetzler-Martin grading scale and the
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presenting clinical status of the patient introduced by the validated ICH scale score. The AVICH-score
assigns one to three points for AVM size, one point for deep venous drainage, one point for eloquence,
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one to three points for age, one point for diffuse nidus, zero to two points for GCS, one point for
hemorrhage greater than 30 cc, and one point for intraventricular hemorrhage.

Although the AVICH-score represents an excellent opportunity to improve our prognostic

accuracy, one important patient centered factor that may be underrepresented by the AVICH-score is
aphasia. Aphasia can exert a profound effect on the outcome in both hemorrhagic and ischemic stroke
as the patient who can meaningfully participate in their own rehabilitation will have a better outcome.
Inclusion of GCS and eloquence attempts to capture this functional information, but may be too crude of
a representation of such a complex prognostic factor. Adding an additional point for aphasia on
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presentation, dominate hemisphere involvement, or language center involvement may improve the
overall predictive value of the scoring model. Patient presentation in the setting of ruptured AVM may
not readily lend itself, however, to this additional assessment.

Conclusions:
Given the ongoing emphasis on outcomes focused Comprehensive Stroke Center accreditation

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and patient centered care, the AVICH-score proposed in the authors’ manuscript provides an additional
opportunity for recognition and accreditation of institutions dedicated to caring for patients with
complex ruptured AVMs presenting in a critical or even moribund state. More precisely, patient

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outcomes become more relevant in the context of presenting status, which this grading scale is uniquely
positioned to elucidate. The authors’ work emphasizes the need for appropriate risk-stratification and
patient triage upon presentation of hemorrhagic stroke patients to Primary Stroke Centers. Risk

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adjustment tools for case mix severity like the AVICH score will be of further importance as attempts are
made to compare outcome metrics across health care providers and to guide potential end-of-life care.

References:

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1. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J.
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Neurosurg. 1986;65 (4): 476-83.
2. Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for
selecting patients with brain arteriovenous malformations for surgery. Neurosurgery.
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2010;66(4):702-13.
3. Kim H, Abla AA, Nelson J, McCulloch CE, Bervini D, Morgan MK, et al. Validation of the
supplemented Spetzler-Martin grading system for brain arteriovenous malformations in a
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multicenter cohort of 1009 surgical patients. Neurosurgery. 2015;76(1):25-31.

4. Hemphill JC, 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple,
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reliable grading scale for intracerebral hemorrhage. Stroke; a journal of cerebral circulation.
2001;32(4):891-7.
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