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Zhu H, Liu L, Chang Y, Song Y, Liang S, Ma C, Zhang L, Liang F, Jiang C, Zhang Y. Quantitative evaluation of the subsequent hemorrhage with arteriography-derived hemodynamic features in patients with untreated cerebral arteriovenous malformation. Front Neurol 2023; 14:1174245. [PMID: 37654429 PMCID: PMC10466408 DOI: 10.3389/fneur.2023.1174245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023] Open
Abstract
Background Patients with untreated cerebral arteriovenous malformations (AVMs) are at risk of intracerebral hemorrhage. However, treatment to prevent AVM hemorrhage carries risks. Objective This study aimed to analyze the AVM nidus-related hemodynamic features and identify the risk factors for subsequent hemorrhage. Methods We retrospectively identified patients with untreated AVMs who were assessed at our institution between March 2010 and March 2021. Patients with ≥6 months of treatment-free and hemorrhage-free follow-up after diagnosed by digital subtraction angiography were included in subsequent examinations. The hemodynamic features were extracted from five contrast flow-related parameter maps. The Kaplan-Meier analyses and Cox proportional hazards regression models were used to find the potential risk factors for subsequent hemorrhage. Results Overall, 104 patients with a mean follow-up duration of 3.37 years (median, 2.42 years; range, 6-117 months) were included in study, and the annual risk of rupture was 3.7%. Previous rupture (hazard ratio [HR], 4.89; 95% confidence interval [CI], 1.16-20.72), deep AVM location (HR, 4.02; 95% CI, 1.01-15.99), higher cerebral blood volume (HR, 3.35; 95% CI, 1.15-9.74) in the nidus, and higher stasis index (HR, 1.54; 95% CI, 1.06-2.24) in the nidus were associated with subsequent hemorrhage in untreated AVMs. Conclusion Higher cerebral blood volume and stasis index in the nidus suggest increased blood inflow and stagnant blood drainage. The combination of these factors may cause subsequent hemorrhage of AVMs.
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Affiliation(s)
- Haoyu Zhu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuzhou Chang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuqi Song
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Chao Ma
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Longhui Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Liang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Chuhan Jiang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Ma L, Yang W, Winkler E, Burkhardt JK, Su H. Editorial: Cerebral and spinal vascular malformations: from bench to bedside. Front Neurol 2023; 14:1235235. [PMID: 37602265 PMCID: PMC10435898 DOI: 10.3389/fneur.2023.1235235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ethan Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Hua Su
- Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, CA, United States
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
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Li R, Chen Y, Li Z, Han H, Chen P, Chen X, Zhao Y. Letter to the Editor. Blood flow analysis for obliteration of AVMs. J Neurosurg 2023; 138:1166-1167. [PMID: 36681983 DOI: 10.3171/2022.9.jns222158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Wang M, Lin F, Qiu H, Cao Y, Wang S, Zhao J. Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations. Front Neurol 2022; 12:756307. [PMID: 35002920 PMCID: PMC8740155 DOI: 10.3389/fneur.2021.756307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation. Methods: Participants in the multicenter prospective clinical trial (NCT03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups. Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs. Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute of Brain Disorder, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Ma L. Commentary on "Signal intensity ratio of draining vein on silent MR angiography as an indicator of high-flow arteriovenous shunt in brain arteriovenous malformation". Eur Radiol 2021; 31:9250-9251. [PMID: 34652521 DOI: 10.1007/s00330-021-08339-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/01/2021] [Accepted: 08/14/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 W Ave 4th S Ring Rd, Fengtai District, 100079, Beijing, People's Republic of China. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.
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Wu CX, Zang ZX, Hong T, Dong MQ, Shan Y, Zhao ZL, Hou CB, Lu J. Signal intensity ratio of draining vein on silent MR angiography as an indicator of high-flow arteriovenous shunt in brain arteriovenous malformation. Eur Radiol 2021; 31:9252-9261. [PMID: 34263361 PMCID: PMC8589750 DOI: 10.1007/s00330-021-08170-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether the signal intensity ratio (rSI) of the draining vein on silent MR angiography is correlated with arteriovenous (A-V) transit time on digital subtraction angiography (DSA), thereby identifying high-flow A-V shunt in brain arteriovenous malformation (BAVM), and to analyze whether the rSI and the characteristic of draining veins on silent MRA are associated with hemorrhage presentation. METHODS Eighty-one draining veins of 46 participants with BAVM (mean age 33.2 ± 16.9 years) who underwent silent MRA and DSA were evaluated retrospectively. The correlation between the rSI of the draining vein on silent MRA and A-V transit time on DSA was examined. The AUC-ROC was obtained to evaluate the performance of the rSI in determining the presence of high-flow A-V shunt. The characteristics of draining veins with the maximum rSI (rSImax) were further compared between the hemorrhagic and non-hemorrhagic untreated BAVM. RESULTS The rSI of each draining vein on silent MRA was significantly correlated with A-V transit time from DSA (r = -0.81, p < .001). The AUC-ROC was 0.89 for using the rSI to determine the presence of high-flow A-V shunt. A cut-off rSI value of 1.09 yielded a sensitivity of 82.4% and a specificity of 82.8%. The draining vein with rSImax and no ectasia was significantly more observed in the hemorrhagic group (p = 0.045). CONCLUSIONS The rSI of the draining vein on silent MRA is significantly correlated with A-V transit time on DSA, and it can be used as an indicator of high-flow A-V shunt in BAVM. KEY POINTS • The signal intensity ratio (rSI) of the draining vein on silent MRA significantly correlated with arteriovenous (A-V) transit time of brain arteriovenous malformation (BAVM) on digital subtraction angiography (DSA). • The area under the receiver operating characteristic curve (AUC) was 0.89 for using the rSI of draining veins to determine high-flow A-V shunt. • Draining veins with maximum rSI and no ectasia were significantly more observed in the hemorrhagic group of BAVM (p = 0.045).
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Affiliation(s)
- Chun-Xue Wu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, 45# Changchun Street, Xicheng District, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Zhen-Xiang Zang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, 45# Changchun Street, Xicheng District, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng-Qi Dong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yi Shan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, 45# Changchun Street, Xicheng District, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Zhi-Lian Zhao
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, 45# Changchun Street, Xicheng District, Beijing, China.,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Cheng-Bei Hou
- Center for Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, 45# Changchun Street, Xicheng District, Beijing, China. .,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China.
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2021; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Chen Y, Meng X, Ma L, Zhao Y, Gu Y, Jin H, Gao D, Li Y, Sun S, Liu A, Zhao Y, Chen X, Wang S. Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey. Chin Neurosurg J 2020; 6:26. [PMID: 32922955 PMCID: PMC7461270 DOI: 10.1186/s41016-020-00206-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In the benefit of the large population and rapid economic growth, the interventional techniques and equipment for brain arteriovenous malformations (bAVMs) in mainland China have been rapidly improved. Chinese neurosurgical cerebrovascular physicians have accumulated rich experience and made pioneering explorations. This study aims to summarize the experience and treatment progress of bAVMs in mainland China. METHODS We performed a web-based nationwide questionnaire survey among 67 tertiary neurosurgical institutions that had acknowledged treating bAVMs in the primary survey. Our questionnaire included clinical characteristics, radiological findings, intervention indications/contraindications, intervention timing, and intraoperative management of different treatment modalities. RESULTS A total of 63 participants from 49 (73.1%) tertiary neurosurgical institutions responded to our questionnaire. Forty-two (66.7%) were neurosurgeons, 13 (20.6%) were neurointerventionists, and 8 (12.7%) were radiosurgeons. Approximately 3500 to 4000 cases of bAVMs were treated annually in these 49 departments. All participants agreed that the conclusions of ARUBA are debatable. Flow-related aneurysms, deep venous drainage, and arteriovenous fistula were considered as common hemorrhagic risk factors. Unruptured SM IV-V bAVMs, giant bAVMs, pediatric bAVMs, elderly bAVMs, and eloquent bAVMs were not absolute contraindications to intervention. Maximum lesion occlusion and minimal functional impairment were the principles of intervention management. Most of the neurosurgeons and neurointerventionists recommended early intervention (< 30 days) for ruptured bAVMs, and the radiosurgeons suggested intervention in the chronic phase or recovery phase (P < 0.01) and preferably 3 months after bleeding. Multi-modality strategies were thought effective for complex bAVMs, and more exploration of individualized intraoperative management was necessary. CONCLUSIONS Intervention was acceptable for specific selected unruptured bAVMs in mainland China, especially in patients with hemorrhagic risk factors. The application of multidisciplinary cerebrovascular team and multicenter large-sample international registry study might be the next work for Chinese neurosurgical cerebrovascular physicians.
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Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Ye Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
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Natural history of high-grade pediatric arteriovenous malformations: implications for management options. Childs Nerv Syst 2020; 36:2055-2061. [PMID: 32166342 DOI: 10.1007/s00381-020-04550-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/18/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Cerebral arteriovenous malformations are a common cause of pediatric intracranial hemorrhage. Often, small, superficial, lesions are treated surgically; however, more complex, deeper, eloquently located lesions portend higher-risk features and suffer from limitations in treatment. We sought to examine our institution's experience with the natural history of these high-grade arteriovenous malformations to explore outcomes with conservative treatment. METHODS A retrospective chart review was performed to identify all pediatric cases of intracranial arteriovenous malformations seen at our institution from 2005 to 2018. Subjects with Spetzler-Martin grade IV or V lesions, treated conservatively, were examined for primary outcomes including rupture rate, progression, and functional outcomes. RESULTS A total of 14 patients were included in the study, of which, 78.57% were classified as Spetzler-Martin grade IV and 21.43% Spetzler-Martin grade V. All patients in this study were treated conservatively, with surveillance, followed for a mean of 32.17 months (range 9.43-79.10). 7.14% experienced delayed hemorrhage or re-rupture, 7.14% had hydrocephalus, and 14.29% had seizures. Neurological sequelae included weakness, visual impairment, speech impairment, sensory changes, and dystonia; functionally independent outcomes, defined as modified Rankin Score of 0-2, were seen in 85.71% of patients. CONCLUSION Our experience suggests that patients with large, deep lesions have significant morbidity with high rates of rupture and subsequent neurologic deficits. However, intervention of these lesions may carry high risk, and the literature suggests such lesions may have less favorable outcomes when treated. We propose conservative treatment for high-grade arteriovenous malformations as a viable option with good functional outcomes in a cohort often without good options for conventional treatment.
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LoPresti MA, Goethe EA, Lam S. Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy. Childs Nerv Syst 2020; 36:1445-1452. [PMID: 31932976 DOI: 10.1007/s00381-020-04501-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children. METHODS A retrospective chart review was conducted examining patients age 0-18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage. RESULTS Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures. CONCLUSIONS Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
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Affiliation(s)
- Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sandi Lam
- Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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11
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Cheng P, Ma L, Shaligram S, Walker EJ, Yang ST, Tang C, Zhu W, Zhan L, Li Q, Zhu X, Lawton MT, Su H. Effect of elevation of vascular endothelial growth factor level on exacerbation of hemorrhage in mouse brain arteriovenous malformation. J Neurosurg 2020; 132:1566-1573. [PMID: 31026826 PMCID: PMC6817409 DOI: 10.3171/2019.1.jns183112] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A high level of vascular endothelial growth factor (VEGF) has been implicated in brain arteriovenous malformation (bAVM) bleeding and rupture. However, direct evidence is missing. In this study the authors used a mouse bAVM model to test the hypothesis that elevation of focal VEGF levels in bAVMs exacerbates the severity of bAVM hemorrhage. METHODS Brain AVMs were induced in adult mice in which activin receptor-like kinase 1 (Alk1, a gene that causes AVM) gene exons 4-6 were floxed by intrabasal ganglia injection of an adenoviral vector expressing Cre recombinase to induce Alk1 mutation and an adeno-associated viral vector expressing human VEGF (AAV-VEGF) to induce angiogenesis. Two doses of AAV-VEGF (5 × 109 [high] or 2 × 109 [low]) viral genomes were used. In addition, the common carotid artery and external jugular vein were anastomosed in a group of mice treated with low-dose AAV-VEGF 6 weeks after the model induction to induce cerebral venous hypertension (VH), because VH increases the VEGF level in the brain. Brain samples were collected 8 weeks after the model induction. Hemorrhages in the bAVM lesions were quantified on brain sections stained with Prussian blue, which detects iron deposition. VEGF levels were quantified in bAVM tissue by enzyme-linked immunosorbent assay. RESULTS Compared to mice injected with a low dose of AAV-VEGF, the mice injected with a high dose had higher levels of VEGF (p = 0.003) and larger Prussian blue-positive areas in the bAVM lesion at 8 or 9 weeks after model induction (p = 0.002). VH increased bAVM hemorrhage in the low-dose AAV-VEGF group. The overall mortality in the high-dose AAV-VEGF group was 26.7%, whereas no mouse died in the low-dose AAV-VEGF group without VH. In contrast, VH caused a mortality of 50% in the low-dose AAV-VEGF group. CONCLUSIONS Using mouse bAVM models, the authors provided direct evidence that elevation of the VEGF level increases bAVM hemorrhage and mouse mortality.
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Affiliation(s)
- Philip Cheng
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Li Ma
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Sonali Shaligram
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Espen J. Walker
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Shun-Tai Yang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Chaoliang Tang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Wan Zhu
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Lei Zhan
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Qiang Li
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Xiaonan Zhu
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, California
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12
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Maynard K, LoPresti M, Iacobas I, Kan P, Lam S. Antiangiogenic agent as a novel treatment for pediatric intracranial arteriovenous malformations: case report. J Neurosurg Pediatr 2019; 24:673-679. [PMID: 31585413 DOI: 10.3171/2019.7.peds1976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/16/2019] [Indexed: 11/06/2022]
Abstract
Intracerebral arteriovenous malformations (AVMs) are high-flow collections of abnormal vessels and a common cause of pediatric intracranial hemorrhage. There are few treatment options available for AVMs not amenable to surgical resection, endovascular embolization, radiosurgery, or multimodality treatment. The authors sought to review the molecular and genetic pathways that have been implicated in the formation of AVMs, focusing on the possibility of medically targeting these pathways in the treatment of AVMs. In the novel case presented here, a pediatric patient who was diagnosed with an intracranial AVM unamenable to conventional treatments underwent alternative treatment with molecular pathway inhibitors.
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Affiliation(s)
- Ken Maynard
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | - Melissa LoPresti
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Ionela Iacobas
- 4Division of Hematology/Oncology, Department of Pediatrics, and
- 5Vascular Anomalies Center, Texas Children's Hospital, Houston; and
- 6Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Sandi Lam
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston
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13
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Huo R, Fu W, Li H, Jiao Y, Yan Z, Wang L, Wang J, Wang S, Cao Y, Zhao J. RNA Sequencing Reveals the Activation of Wnt Signaling in Low Flow Rate Brain Arteriovenous Malformations. J Am Heart Assoc 2019; 8:e012746. [PMID: 31170876 PMCID: PMC6645621 DOI: 10.1161/jaha.119.012746] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background The blood flow rate of brain arteriovenous malformations (bAVMs) is an important clinical characteristic closely associated with the hemorrhage risk and radiosurgery obliteration rate of bAVMs. However, the underlying molecular properties remain unclear. To identify potential key molecules, signaling pathways, and vascular cell types involved, we compared gene expression profiles between bAVMs with high flow rates and low flow rates (LFR) and validated the functions of selected key molecules in vitro. Methods and Results We performed RNA‐sequencing analysis on 51 samples, including 14 high flow rate bAVMs and 37 LFR bAVMs. Functional pathway analysis was performed to identify potential signals influencing the flow rate phenotype of bAVMs. Candidate genes were investigated in bAVM specimens by immunohistochemical staining. Migration, tube formation, and proliferation assays were used to test the effects of candidate genes on the phenotypic properties of cultured human umbilical vein endothelial cells and human brain vascular smooth muscle cells. We identified 250 upregulated and 118 downregulated genes in LFR bAVMs compared with high flow rate bAVMs. Wnt signaling was activated in the LFR group via upregulation of FZD10 and MYOC. Immunohistochemical staining showed that vascular endothelial and smooth muscle cells of LFR bAVMs exhibited increased FZD10 and MYOC expression. Experimentally elevating these genes promoted human umbilical vein endothelial cells and migration and tube formation by activating canonical Wnt signaling in vitro. Conclusions Our results suggest that canonical Wnt signaling mediated by FZD10 and MYOC is activated in vascular endothelial and smooth muscle cells in LFR bAVMs.
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Affiliation(s)
- Ran Huo
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Weilun Fu
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Hao Li
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Yuming Jiao
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Zihan Yan
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Linjian Wang
- 5 Savaid Medical School University of the Chinese Academy of Sciences Beijing China
| | - Jie Wang
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Shuo Wang
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Yong Cao
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Jizong Zhao
- 1 Department of Neurosurgery Beijing Tiantan Hospital Capital Medical University Beijing China.,2 China National Clinical Research Center for Neurological Diseases Beijing China.,3 Center of Stroke Beijing Institute for Brain Disorders Beijing China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China.,5 Savaid Medical School University of the Chinese Academy of Sciences Beijing China
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14
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Dinc N, Won SY, Eibach M, Gessler F, Konczalla J, Quick-Weller J, Seifert V, Marquardt G. The Extent of Neurologic Improvement and Social Life in Young Patients with Ruptured and Unruptured Brain AVM: A Long-Term Follow-Up. World Neurosurg 2019; 127:e503-e508. [PMID: 30928578 DOI: 10.1016/j.wneu.2019.03.187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/16/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intracerebral hemorrhage, seizures, neurologic deficits, and cognitive impairments due to brain AVM in childhood are incriminating for brain and executive function with sequelae for further social life. Long-term follow-up data on brain AVM in young patients are rare, making it difficult to compare and evaluate treatment risks and outcomes. METHODS We studied young patients with brain AVM who were referred to our institution between 2005 and 2012 and for whom follow-up data were available. We stratified the patients into those with ruptured AVM (rAVM) and unruptured AVM (uAVM) and compared treated and nontreated patients. Differences in outcome and social participation were assessed. RESULTS A total of 29 young patients with brain AVM, median age 16 years, were included in our study with complete follow-up data of over 5 years (mean, 6 years). In 18 (62.1%) patients rAVM and in 11 (37.9%) patients uAVM were found. Twenty (69%) patients received treatment (rAVM 70% vs. uAVM 30%). Among treatment methods, microsurgery was most frequently used (rAVM 33.3% vs. uAVM 36.4%). In rAVM, 16 of 18 (88.9%) patients returned to work or school, and in uAVM, 11 (100%) patients did so. Concerning cognitive problems, no statistically significant difference was found in the 2 groups comparing treated and nontreated patients (P > 0.05). A favorable outcome was achieved in 13 (72.2%) patients with rAVM and in 11 (100%) patients with uAVM. CONCLUSION Favorable outcome was achieved in the majority of patients. The rate of neurologic improvement and participation in social life was very high in the 2 groups.
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Affiliation(s)
- Nazife Dinc
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany.
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Michael Eibach
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | | | - Volker Seifert
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Gerhard Marquardt
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
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15
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Ai X, Ye Z, Xu J, You C, Jiang Y. The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis. J Neurosurg Pediatr 2019; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/06/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs. METHODS The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients. CONCLUSIONS Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation. ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; NOS = Newcastle-Ottawa Scale; OR = odds ratio; SM = Spetzler-Martin.
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Affiliation(s)
| | | | | | | | - Yan Jiang
- 2Nursing Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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16
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Stefani MA, Sgarabotto Ribeiro D, Mohr JP. Grades of brain arteriovenous malformations and risk of hemorrhage and death. Ann Clin Transl Neurol 2019; 6:508-514. [PMID: 30911574 PMCID: PMC6414495 DOI: 10.1002/acn3.723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 11/13/2022] Open
Abstract
Objective To assess the relationship of the grade of unruptured and untreated Brain Arteriovenous Malformations (AVMs), with the risk of subsequent stroke and death during follow‐up. Methods This prospective study was drawn from a cohort of adult patients with unruptured AVMs, who participated in the conservative treatment arm (medical management only for headache or seizures) of the randomized clinical trial of unruptured brain AVMs (ARUBA study). The grade of AVMs (Spetzler–Martin scale) was dichotomized into categories: AVMs of grades I and II were considered low grade; AVMs of grades III and IV were considered high grade. There were no grade V AVM patients in ARUBA. The primary outcome was symptomatic stroke (hemorrhagic or ischemic – documented by imaging) or death. Results The conservative treatment group had 123 patients (“as treated” analysis). 71 (57.7%) had lesions characterized for this analysis as low‐grade lesions and 52 (42.2%) as high grade. From the total of 10 (8.13%) primary outcomes, three occurred (4.22%) in low‐grade AVMs and seven (13.46%) in high‐grade AVMs (P = 0.0942). Interpretation Statistical analysis of the cohort of patients with unruptured and untreated AVMs from ARUBA study showed that the graduation categories (Spetzler–Martin grades) were not associated with the outcome of subsequent stroke or death.
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Affiliation(s)
- Marco A Stefani
- Postgraduate Program in Surgical Sciences Faculty of Medicine Federal University of Rio Grande do Sul Porto Alegre Brazil.,Department of Morphological Sciences Institute of Basic Health Sciences Federal University of Rio Grande do Sul Porto Alegre Brazil.,Neurosurgeon at Moinhos de Vento Hospital Porto Alegre Brazil
| | - Diego Sgarabotto Ribeiro
- Postgraduate Program in Surgical Sciences Faculty of Medicine Federal University of Rio Grande do Sul Porto Alegre Brazil.,Radiologist and Neuroradiologist Porto Alegre Brazil
| | - Jay P Mohr
- Neurologist at the Institute of Neurology Columbia University Medical Center New York New York
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17
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Huang Z, Peng K, Chen C, Zeng F, Wang J, Chen F. A Reanalysis of Predictors for the Risk of Hemorrhage in Brain Arteriovenous Malformation. J Stroke Cerebrovasc Dis 2018; 27:2082-2087. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/03/2018] [Accepted: 03/08/2018] [Indexed: 10/17/2022] Open
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18
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Li Z, Ma L, Wu C, Ma J, Chen X. Pediatric brain arteriovenous malformation unfavorable hemorrhage risk: extrapolation to a morphologic model. Chin Neurosurg J 2018; 4:15. [PMID: 32922876 PMCID: PMC7398325 DOI: 10.1186/s41016-018-0123-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022] Open
Abstract
Background Children with brain arteriovenous malformations (bAVM) are at risk of life-threatening hemorrhage contributing to unfavorable neurological deficit in their early lives. Our aim was to propose a classification system predicting the unfavorable hemorrhage in children with bAVM. Methods We identified all consecutive children admitted to our institution for bAVMs between July 2009 and August 2015. A hemorrhage event was defined as unfavorable when it is life-threatening (requiring emergent invasive intervention) or with post-hemorrhage mRS > 3. The effects of demographic characteristics and bAVM morphology on unfavorable hemorrhage risk were studied using univariate and multivariable regression analyses, followed by discrimination analysis using area under the receiver operating curve (AUROC) and 5-fold cross validation. Results A total of 162 pediatric bAVM cases were identified, unfavorable hemorrhage occurred in 49 (30.2%). Periventricular nidus location (HR, 4.46; 95%CI, 1.93–10.31; P < 0.001), non-temporal lobe location (HR, 2.72; 95%CI, 1.20–6.15; P = 0.02) and long pial draining vein (HR, 3.26; 95%CI, 1.53–6.97; P = 0.002) were independent predictors of an earlier unfavorable hemorrhage in pediatric bAVMs. We further classified the bAVM into three types: Type I, periventricular and non-temporal location (Ia, deep location; Ib, superificial location); Type II, with long pial draining vein and non-periventricular or temporal location; Type III, non-periventricular or temporal location without long draining vein. Predictive accuracy of this classification for unfavorable hemorrhage was assessed with AUROC of 0.77 (95% CI 0.69–0.85) and remained stable after cross validation. Conclusion A morphologic model based on nidus location and venous drainage might predict unfavorable hemorrhage in children with bAVM.
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Affiliation(s)
- Zongze Li
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China
| | - Li Ma
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Chunxue Wu
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jun Ma
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaolin Chen
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
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19
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Wu CX, Ma L, Chen XZ, Chen XL, Chen Y, Zhao YL, Hess C, Kim H, Jin HW, Ma J. Evaluation of Angioarchitectural Features of Unruptured Brain Arteriovenous Malformation by Susceptibility Weighted Imaging. World Neurosurg 2018; 116:e1015-e1022. [PMID: 29859363 DOI: 10.1016/j.wneu.2018.05.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/20/2018] [Accepted: 05/22/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES A precise assessment of angioarchitectural characteristics using noninvasive imaging is helpful for serial follow-up and weighting risk of natural history in unruptured brain arteriovenous malformation (bAVM). This study aimed to test the hypothesis that susceptibility weighted imaging (SWI) would provide an accurate evaluation of angioarchitectural features of unruptured bAVM. METHODS A total of 81 consecutive patients with unruptured bAVM were examined. Image quality of SWI for the assessment of bAVM angioarchitectural features was determined by a 5-point scale. The accuracy of SWI for detection of angioarchitectural features was evaluated using digital subtraction angiography as a standard reference and further compared among unruptured bAVMs with or without silent intralesional microhemorrhage on SWI to examine the potential confounding effect of microhemorrhage on image analysis. RESULTS All lesions were identified on SWI. Image quality of SWI was judged to be at least adequate for diagnosis (range, 3-5) in all patients by both readers. Using digital subtraction angiography as a reference standard, the area under the receiver operating curve of detection of deep or posterior fossa location, exclusively deep venous drainage, venous ectasia, venous varices, and the presence of associated aneurysm on SWI was 1, 0.93, 0.94, 0.95, and 0.83, respectively. Silent intralesional microhemorrhage were detected in 39 patients (48.15%) on SWI and no significant difference (P > 0.05) was found in angioarchitectural features between patients with and without silent microhemorrhage. CONCLUSIONS SWI might be a noninvasive alternative technique for angiography in the angioarchitectural assessment of unruptured bAVM.
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Affiliation(s)
- Chun-Xue Wu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China
| | - Li Ma
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xu-Zhu Chen
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China
| | - Xiao-Lin Chen
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yu Chen
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yuan-Li Zhao
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Christopher Hess
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Heng-Wei Jin
- Interventional Neuroradiology Beijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China
| | - Jun Ma
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Dongcheng District, Beijing, People's Republic of China.
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20
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Ma L, Kim H, Chen XL, Wu CX, Ma J, Su H, Zhao Y. Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation. Cerebrovasc Dis 2017; 43:231-241. [PMID: 28241126 DOI: 10.1159/000458731] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 02/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Children with untreated brain arteriovenous malformations (bAVM) are at risk of encountering life-threatening hemorrhage very early in their lives. The primary aim of invasive treatment is to reduce unfavorable outcome associated with a bAVM rupture. A better understanding of the morbidity of bAVM hemorrhage might be helpful for weighing the risks of untreated bAVM and invasive treatment. Our aim was to assess the clinical outcome after bAVM rupture and identify features to predict severe hemorrhage in children. METHODS We identified all consecutive children admitted to our institution for bAVMs between July 2009 and December 2014. Clinical outcome after hemorrhagic presentation and subsequent hemorrhage was evaluated using the modified Rankin Scale (mRS) for children. The association of demographic characteristics and bAVM morphology with severe hemorrhage (mRS >3 or requiring emergency hematoma evacuation) was studied using univariate and multivariable regression analyses. A nomogram based on multivariable analysis was formulated to predict severe hemorrhage risk for individual patients. RESULTS A total of 134 patients were identified with a mean treatment-free follow-up period of 2.1 years. bAVM ruptured in 83 (62%) children: 82 had a hemorrhage at presentation and 6 of them experienced a recurrent hemorrhage during follow-up; 1 patient had other diagnostic symptoms but bled during follow-up. Among them, 49% (41/83) had a severe hemorrhage; emergency hematoma evacuation was required in 28% of them (23/83), and 24% (20/83) remained as disabled (mRS ≥3) at last follow-up. Forty-six percent (38/82) of children with hemorrhagic presentation were severely disabled (mRS >3). Forty-three percent (3/7) were severely disabled after subsequent hemorrhage. The annual rate of severe subsequent hemorrhage was 1% in the overall cohort and 3.3% in children with ruptured presentation. All the subsequent severe hemorrhage events occurred in children with severe hemorrhage history (7%, 3/41). Periventricular location, non-temporal lobe location, and long draining vein were predictors for severe hemorrhage in pediatric untreated bAVMs. A nomogram based on bAVM morphology was contracted to predict severe hemorrhage risk for individual patients, which was well calibrated and had a good discriminative ability (adjusted C-statistic, 0.72). CONCLUSIONS Evaluating bAVM morbidity and morphology might be helpful for weighing the risks of untreated bAVM in pediatric patients.
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Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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Shtaya A, Millar J, Sparrow O. Multimodality management and outcomes of brain arterio-venous malformations (AVMs) in children: personal experience and review of the literature, with specific emphasis on age at first AVM bleed. Childs Nerv Syst 2017; 33:573-581. [PMID: 28324183 PMCID: PMC5382178 DOI: 10.1007/s00381-017-3383-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/10/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this paper is to study the presentation and analyse the results of multimodality treatment of brain arterio-venous malformations (AVMs) in children at our centre and review age at first AVM rupture in the literature. METHODS Of 52 patients aged <18 years, 47 with brain AVMs (27 males and 20 females) aged 4-17 years (mean 12.2) were retrospectively reviewed. PubMed search revealed five additional studies including 267 patients where the prevalence of age-related AVMs rupture was analysed. RESULTS In our study, 37 patients had bled, 9 were symptomatic without haemorrhage and 1 was incidental. Spetzler-Martin score distribution was 5 cases grade I, 18 grade II, 21 grade III and 3 grade IV. Appropriate imaging was performed, either CT/MRI angiogram only (in emergency cases) or catheter angiogram, prior to definitive treatment. There were 40 supratentorial and 7 infratentorial AVMs. Twenty-nine patients had microsurgery alone and 9 patients were treated by radiosurgery only. Three patients were embolised, all followed by radiosurgery, with one requiring surgery too, while 4 patients had combined surgery and radiosurgery. One patient is awaiting radiosurgery while another was not treated. Good outcomes, classified as modified Rankin score (mRS) 0-2 improved significantly after intervention to 89.4% from 38.3% pre-treatment (p value <0.0001). Angiography confirmed 96.6% obliteration after first planned operation. Repeat cerebral angiogram around age 18 was negative in all previously cured patients. Reviewing the literature, 82.0% (95% CI = [77-87]; N = 267) of children diagnosed with brain AVMs (mean age 11.4 ± 0.4) presented with a bleed in the last 22 years. Males significantly outnumbered females (136 vs 84) (p < 0.001). Ninety-five patients underwent surgical intervention alone when compared to other treatment modalities (p < 0.001). CONCLUSIONS Microsurgical excision of surgically accessible intracranial AVMs remains the primary treatment option with very good outcomes. A significant number of patients' AVMs ruptured around puberty; therefore, understanding the pathophysiology of AVM instability at this age may aid future therapy.
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Affiliation(s)
- Anan Shtaya
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK. .,Atkinson Morley Neurosurgery Centre, Academic Neurosurgery Unit, St George's, University of London, London, SW17 0RE, UK.
| | - John Millar
- 0000000103590315grid.123047.3Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Owen Sparrow
- 0000000103590315grid.123047.3Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
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