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Aziz N, Duddy JC, Saeed D, Hennigan D, Israni A, Puthuran M, Chandran A, Mallucci C. Multi-modality treatment approach for paediatric AVMs with quality-of-life outcome measures. Childs Nerv Syst 2023; 39:2439-2447. [PMID: 37198451 DOI: 10.1007/s00381-023-05954-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Despite the potentially devastating and permanently disabling effects of paediatric arteriovenous malformations (pAVMs), there is a paucity of studies reporting long-term quality-of-life (QoL) outcomes in AVM patients. We aim to evaluate the management strategies for paediatric intracranial pAVMs in the UK and long-term QoL outcomes using a validated paediatric quality-of-life outcome measure. METHODS In this single-centre case-series, we retrospectively reviewed a prospectively maintained database of all paediatric patients (i.e. 0-18 years old) with intracranial AVMs, who were managed at Alder Hey Children's Hospital from July 2007 to December 2021. We also collected the PedsQL 4.0 score for these patients as a measure of QoL. RESULTS Fifty-two AVMs were included in our analysis. Forty (80%) were ruptured, 8 (16%) required emergency intervention, 17 (35%) required elective surgery, 15 (30%) underwent endovascular embolisation, and 15 (30%) patients underwent stereotactic radiosurgery. There was an 88% overall obliteration rate. Two (4%) pAVMs rebled, and there were no mortalities. Overall, the mean time from diagnosis to definitive treatment was 144 days (median 119; range 0-586). QoL outcomes were collected for 26 (51%) patients. Ruptured pAVM presentation was associated with worse QoL (p = 0.0008). Location impacted psychosocial scores significantly (71.4, 56.9, and 46.6 for right supratentorial, left supratentorial, and infratentorial, respectively; p = 0.04). CONCLUSION This study shows a staged multi-modality treatment approach to pAVMs is safe and effective, with superior obliteration rates with surgery alone. QoL scores are impacted by AVM presentation and location regardless of treatment modality.
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Affiliation(s)
- Natasha Aziz
- School of Medicine, University of Liverpool, Liverpool, UK.
| | - John C Duddy
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Danial Saeed
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Dawn Hennigan
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Anil Israni
- Department of Neurology, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Mani Puthuran
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Arun Chandran
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
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Jha VC, Alam MS, Sinha VS. Comparative outcome of endovascular embolization with microsurgery in managing acute spontaneous cerebral hemorrhage in pediatric patients, an institutional experience. Childs Nerv Syst 2022; 39:963-974. [PMID: 36571597 DOI: 10.1007/s00381-022-05785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES A few previous studies have reported the role of embolization with curative intent in the treatment of the early phase of a spontaneous cerebral hemorrhage in pediatric patients, and its efficacy needs to be compared with surgery at the same time risk factors for hemorrhage following early embolization in such patients need to be evaluated. METHODS From a pool of 80 pediatric (< 18 years) who had undergone treatment for ruptured AVM with hemorrhage at our center between July 2018 and July 2022, we identified 36 patients with spontaneous bleeding due to AVM. Out of which, 20 were treated solely by embolization (group 1), while the remaining patients were treated surgically (with and without adjuvant embolization) (group 2). RESULT Spetzler-Martin's grading of the lesion suggested seven lesions < 3 and 13 lesions ≥ 3 in the embolization group. Similarly, seven lesions were < 3 and nine ≥ 3 Spetzler-Martin grade in the surgery group. Incomplete embolization was associated with hemorrhage in two patients treated with curative intent and four patients treated with embolization as adjuvant in the surgery group (p = 0.01). On follow-up, 18 patients in the embolization group and 12 in the surgery group had Glasgow outcome scores ≥ 4 (p = 0.273). CONCLUSION In the pediatric age group, incomplete embolization is the significant risk factor for hemorrhage in AVMs treated after a hemorrhagic stroke. Embolization with curative intent is as effective as surgery in treating such lesions as adjuvant embolization with careful patient selection.
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Affiliation(s)
- Vikas Chandra Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | | | - Vivek Sharan Sinha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
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Oulasvirta E, Pohjola A, Koroknay-Pál P, Hafez A, Roine R, Sintonen H, Laakso A. Long-term health-related quality of life in patients with ruptured arteriovenous malformations treated in childhood. J Neurosurg Pediatr 2022; 30:292-300. [PMID: 35901751 DOI: 10.3171/2022.5.peds2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to reveal the long-term health-related quality of life (HRQOL), educational level, and impact on occupation in 55 patients who experienced ruptured brain arteriovenous malformations (AVMs) that were treated during childhood. METHODS In 2016, questionnaires including the 15D instrument were sent to all living patients older than 18 years (n = 432) in the Helsinki AVM database. The cohort was further specified to include only patients with ruptured AVMs who were younger than 20 years at the time of diagnosis (n = 55). Educational level was compared with the age-matched general population of Finland. The mean 15D scores were calculated for independent variables (Spetzler-Ponce classification, admission age, symptomatic epilepsy, and multiple bleeding episodes) and tested using the independent-samples t-test or ANCOVA. Linear regression was used to create a multivariate model. Bonferroni correction was used with multiple comparisons. RESULTS The mean follow-up time from diagnosis to survey was 24.2 (SD 14.7) years. The difference in the mean 15D scores between Spetzler-Ponce classes did not reach statistical significance. The youngest age group (< 10 years at the time of diagnosis) performed less well on the dimension of usual activities than the older patients. Symptomatic epilepsy significantly reduced the long-term HRQOL. Multiple hemorrhages significantly reduced the scores on three dimensions: mobility, speech, and sexual activity. In the regression model, symptomatic epilepsy was the only significant predictor for a lower 15D score. The educational level of the cohort was for the most part comparable to that of the general population in the same age group. AVM was the reason for early retirement in 11% of the patients, while lowered performance because of the AVM was reported by 37% of the patients. CONCLUSIONS Patients with ruptured AVMs treated in childhood can live an independent and meaningful life, even in the case of the highest-grade lesions. Symptomatic epilepsy significantly reduced the long-term HRQOL, highlighting the need for continuing support for these patients.
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Affiliation(s)
- Elias Oulasvirta
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Anni Pohjola
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Päivi Koroknay-Pál
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Ahmad Hafez
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Risto Roine
- 2Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland; and
| | - Harri Sintonen
- 3Department of Public Health, Helsinki University Hospital, Helsinki, Finland
| | - Aki Laakso
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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4
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho-Caballero K, Mayoria-Vargas A, Rodríguez-Varela R, Saal-Zapata G. Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients. Childs Nerv Syst 2022; 38:343-351. [PMID: 34605999 DOI: 10.1007/s00381-021-05376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. METHODS Patients between 1 and 18 years of age undergoing endovascular embolization between 2011 and 2020 were included. RESULTS A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6 cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. CONCLUSIONS Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru. .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru.
| | - Kiara Camacho-Caballero
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru.,CHANGE, Research Working Group, Carrera de Medicina Humana, Universidad Cientifica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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Rodesch G, Smajda S. Complications in pediatric interventional neuroradiology management. Reflections on a personal experience. Interv Neuroradiol 2020; 26:741-751. [PMID: 32588707 PMCID: PMC7724602 DOI: 10.1177/1591019920935311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/26/2020] [Indexed: 08/25/2023] Open
Abstract
Pediatric interventional neuroradiology is a rewarding but demanding specialty. It cannot be classified as a miniaturized technical procedure simply because it deals with small vessels in small patients but remains a field requiring specific knowledge combining clinical, anatomical, physiologic, and technical features. Complications that occur remain terrible experiences in this population whose patients have not personally requested to be treated for their vascular malformations. The aim of this article is to evoke the various possible groups of complications that may occur during a pediatric endovascular procedure in order to make physicians aware of these problems and help them to avoid them.
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Affiliation(s)
- Georges Rodesch
- Department of Diagnostic and Therapeutic
Neuroradiology, Hôpital Foch, Suresnes, France
| | - Stanislas Smajda
- Pediatric Interventional Neuroradiology
Unit, Department of Interventional Neuroradiology, Fondation Rothschild, Paris,
France
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7
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Lubicz B, Christiaens F. Endovascular treatment of intracranial vascular malformations in children. Dev Med Child Neurol 2020; 62:1124-1130. [PMID: 32533582 DOI: 10.1111/dmcn.14589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 11/26/2022]
Abstract
Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis.
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Affiliation(s)
- Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Florence Christiaens
- Department of Pediatric Neurology, Erasme University Hospital, Brussels, Belgium
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Abstract
Cerebral arteriovenous malformations (AVMs) are a complex and heterogeneous pathology which require an understanding of the natural history of these lesions, as well as the potential treatment options in order to manage them safely. While treatment is the agreed upon strategy for most ruptured AVMs, the management of unruptured AVMs continues to be debated. More recently, this debate has been fueled by the A Randomized Trial of Unruptured Arteriovenous Malformations (ARUBA) trial which attempts to define the natural history and treatment risk of AVMs. However, the trial has significant shortcomings which limit its broad applicability. In addition, the breadth, efficacy, and safety of potential treatment options continue to improve. This review focuses on defining the natural history of cerebral AVMs, an overview of the ARUBA trial, and the most current treatment paradigm for cerebral AVMs.
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9
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Lu VM, Wahood W, Rinaldo L, Ahn ES, Daniels DJ. Long-term functional outcome after intervention for pediatric intracranial arteriovenous malformations: A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 191:105707. [PMID: 32018117 DOI: 10.1016/j.clineuro.2020.105707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/15/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
Intervention (surgery, embolization, and radiosurgery) is critical in maximizing outcomes of pediatric arteriovenous malformations (pAVMs). Although short-term functional outcomes following intervention have been stablished to be favorable, long-term outcomes have yet to be thoroughly consolidated. Searches of 7 electronic databases from inception to April 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Favorable functional were modified Rankin Scale (mRS) scores ranging from 0 to 2, and the incidences were extracted and pooled by random-effects meta-analysis of proportions. Fourteen pertinent studies were identified describing outcomes of 699 pAVM patients, with median 75 % presenting with hemorrhage. Surgery, embolization and radiosurgery use were reported by 12 (86 %), 14 (100 %) and 10 (71 %) studies respectively. By median study follow-up time of 4.1 years, a favorable functional outcome was estimated to occur in 87 % (95 % CI, 82-91 %) of subjects respectively. Hemorrhagic versus non-hemorrhagic presentations did not statistically differ in incidence of this long-term outcome, 78 % (95 % CI, 67-87 %) and 91 % (95 % CI, 80-98 %) respectively. This study demonstrates that favorable long-term functional outlook of pAVM subjects after intervention can persist for many years after initial intervention. The certainty of achieving this outcome is moderate, irrespective of hemorrhagic presentation or intervention modality. Long-term functional deficit risk should not be the sole factor in deciding if intervention should be pursued.
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Affiliation(s)
- Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
| | - Waseem Wahood
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
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LoPresti MA, Ravindra VM, Pyarali M, Goethe E, Gadgil N, Wagner K, Kan P, Lam S. Pediatric intracranial arteriovenous malformations: a single-center experience. J Neurosurg Pediatr 2020. [DOI: 10.3171/2019.9.peds19235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIntracranial arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. Exploring outcomes of treatment and factors that predict recurrence may help guide the management of pediatric AVMs. In this study, the authors review a single-center experience with pediatric AVMs, aiming to identify factors contributing to recurrence and areas for improvement in treatment.METHODSA single-center retrospective review of patients ages 0–18 years with AVMs in the period from 2005 to 2018 was conducted. Demographic, clinical, and radiographic data were collected and examined to compare the clinical and functional outcomes of patients managed with and those managed without open microsurgical resection.RESULTSOne hundred five patients were diagnosed and treated during the study period. Fifty (47.6%) had been treated surgically and 35 (33.3%) nonsurgically, and 20 (19%) had been treated primarily at an outside institution and thus were excluded from further analysis. Of the 50 treated surgically, 92% had complete obliteration on postoperative imaging, with the remaining patients having residual AVM and undergoing re-resection or SRS, ultimately resulting in a 96% radiographic cure rate. The surgically treated patients were followed up for an average of 3.34 years. Eighty-two percent had a modified Rankin Scale (mRS) score of 0–2. There was a recurrence rate of 12%, with the time to recurrence averaging 327.86 days (range 85–596 days). Of the 35 patients managed without open surgery, 77% underwent serial imaging surveillance, 20% underwent endovascular embolization, and 3% underwent stereotactic radiosurgery. Radiographic cure was seen in 6% of those treated nonsurgically, and all had undergone endovascular treatment alone. The nonsurgically treated patients were followed up for an average of 2.14 years. Eighty percent had an mRS score of 0–2.CONCLUSIONSThe data revealed that patients with lower-grade AVMs treated surgically and those with higher-grade AVMs managed without surgery have good functional and clinical outcomes. A high rate of recurrence was noted, and the possible contributing factors were explored. The authors encourage further study into mechanisms to reduce AVM recurrence in pediatric patients and look forward to advances in the medical management of lesions that are considered unresectable.
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Affiliation(s)
- Melissa A. LoPresti
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Vijay M. Ravindra
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Monika Pyarali
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Eric Goethe
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nisha Gadgil
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Kathyrn Wagner
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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LoPresti MA, Giridharan N, Pyarali M, Gadgil N, Kan PT, Niedwiekci C, Lam SK. Pediatric intracranial arteriovenous malformations: Examining rehabilitation outcomes. J Pediatr Rehabil Med 2020; 13:7-15. [PMID: 32176668 DOI: 10.3233/prm-190609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Arteriovenous malformation (AVM) rupture in children can cause debilitating neurological injury. Rehabilitation is key to recovery, though literature details little regarding rehabilitation outcomes. We examined a single-center experience with pediatric AVMs as related to acute inpatient rehabilitation outcomes. METHODS At our institution, a retrospective chart review was completed examining all cases of intracranial AVMs in patients age 18 and younger who completed our acute inpatient rehabilitation program between 2012-2018. Patient characteristics, clinical data, treatment modality, and functional outcomes were reviewed. RESULTS 14 patients with AVMs underwent acute inpatient rehabilitation; nine (64.3%) treated surgically at our institution, two (14.3%) non-surgically at our institution, and three (21.4%) surgically at an outside facility prior to transitioning care at our institution. Eight (57.1%) were male, seven (50.0%) Caucasian, and seven (50.0%) Hispanic. Seven (50.0%) presented with AVM rupture; six (42.9%) were found incidentally on imaging. Clinical courses, treatment outcomes, and post-treatment complications varied. Several patients underwent repeat treatment or additional procedures. Neurological deficits identified included hemiparesis, dystonia, spasticity, epilepsy, hydrocephalus, and ataxia. Inpatient rehabilitation unit length of stay was on average 21 days (SD 9.02, range 9-41). Functional Independence Measure for Children (WeeFIM®) scores, including self-care, mobility, and cognition, demonstrated improvement upon discharge. The mean total change was 36.7 points in those treated surgically, 16.5 in those treated non-surgically, and 25.7 in those treated surgically at another facility. CONCLUSION We found that all pediatric patients with intracranial AVMs, across all treatment modalities, demonstrated improved outcomes across all functional domains after an acute inpatient rehabilitation program.
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Affiliation(s)
- Melissa A LoPresti
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nisha Giridharan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Monika Pyarali
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nisha Gadgil
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Peter T Kan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Christian Niedwiekci
- Department of Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, TX, USA
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, Department of Neurosurgery, Northwestern University, Chicago, IL, USA
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Tam KY, Lim K, Zhu CXL, Chan KY, Poon WS, Poon D, Kam M, Cheung M, Wong KCG. Long-term outcomes of ruptured cerebral arteriovenous malformations in the paediatric population: A retrospective review in a regional hospital in Hong Kong. J Clin Neurosci 2019; 66:66-70. [DOI: 10.1016/j.jocn.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
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Hasegawa T, Kato T, Naito T, Tanei T, Torii J, Ishii K, Tsukamoto E. Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 1: Analysis of Nidus Obliteration Rates and Related Factors. World Neurosurg 2019; 126:e1518-e1525. [PMID: 30922904 DOI: 10.1016/j.wneu.2019.03.176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Little is known about long-term outcomes for pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS). This study investigated annual hemorrhage rates and nidus obliteration rates, and the factors affecting them, in pediatric AVMs treated with GKRS. METHODS We examined 189 pediatric AVM patients (age ≤15 years) who underwent GKRS and had at least 12 months of follow-up. The Spetzler-Martin (S-M) grade was I in 29 patients (15%), II in 57 (30%), III in 82 (43%), IV in 16 (9%), and V in 5 (3%). The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS The mean follow-up period was 136 months. During a cumulative latency period to nidus obliteration of 813 years, 23 hemorrhages occurred, resulting in an annual post-GKRS hemorrhage rate of 2.8%. The cumulative hemorrhage rates after GKRS were 3.3%, 8.5%, and 11.9% at 3, 5, and 10 years, respectively. Higher S-M grade was significantly associated with intracranial hemorrhages during the latency period (P < 0.001). The actuarial nidus obliteration rates with repeated GKRS were 64% and 81% at 5 and 10 years, respectively. Absence of pre-GKRS embolization (P = 0.023) and higher marginal dose (P = 0.029) were significant factors predicting nidus obliteration. CONCLUSIONS GKRS is a reasonable treatment option in pediatric AVMs to prevent future hemorrhages. Because higher S-M grade AVMs are more likely to hemorrhage during the latency period, a combined therapy with endovascular embolization should be considered to prevent AVM rupture.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan.
| | - Takenori Kato
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takehiro Naito
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Jun Torii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Eisuke Tsukamoto
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
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