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Davison M, McCune M, Thiyagarajah N, Kashkoush A, Achey R, Shost M, Toth G, Bain M, Moore N. The incidence of infratentorial arteriovenous malformation-associated aneurysms: an institutional case series and systematic literature review. J Neurointerv Surg 2024:jnis-2024-022003. [PMID: 38937081 DOI: 10.1136/jnis-2024-022003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Arteriovenous malformation (AVM)-associated aneurysms represent a high-risk feature predisposing them to rupture. Infratentorial AVMs have been shown to have a greater incidence of associated aneurysms, however the existing data is outdated and biased. The aim of our research was to compare the incidence of supratentorial vs infratentorial AVM-associated aneurysms. METHODS Patients were identified from our institutional AVM registry, which includes all patients with an intracranial AVM diagnosis since 2000, regardless of treatment. Records were reviewed for clinical details, AVM characteristics, nidus location (supratentorial or infratentorial), and presence of associated aneurysms. Statistical comparisons were made using Fisher's exact or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis determined independent predictors of AVM-associated aneurysms. As a secondary analysis, a systematic literature review was performed, where studies documenting the incidence of AVM-associated aneurysms stratified by location were of interest. RESULTS From 2000-2024, 706 patients with 720 AVMs were identified, of which 152 (21.1%) were infratentorial. Intracranial hemorrhage was the most common AVM presentation (42.1%). The incidence of associated aneurysms was greater in infratentorial AVMs compared with supratentorial cases (45.4% vs 20.1%; P<0.0001). Multivariable logistic regression demonstrated that infratentorial nidus location was the singular predictor of an associated aneurysm, odds ratio: 2.9 (P<0.0001). Systematic literature review identified eight studies satisfying inclusion criteria. Aggregate analysis indicated infratentorial AVMs were more likely to harbor an associated aneurysm (OR 1.7) and present as ruptured (OR 3.9), P<0.0001. CONCLUSIONS In this modern consecutive patient series, infratentorial nidus location was a significant predictor of an associated aneurysm and hemorrhagic presentation.
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Affiliation(s)
- Mark Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Maximos McCune
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | | | - Ahmed Kashkoush
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Shost
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Nina Moore
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
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Li R, Chen Y, Chen P, Ma L, Han H, Li Z, Zhou W, Chen X, Zhao Y. Lesion-Filling Index from Quantitative DSA Correlates with Hemorrhage of Cerebral AVM. AJNR Am J Neuroradiol 2024; 45:712-720. [PMID: 38697788 PMCID: PMC11288585 DOI: 10.3174/ajnr.a8218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/02/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND PURPOSE Rupture is the most life-threatening manifestation of cerebral AVMs. This study aimed to explore the hemodynamic mechanism of AVM rupture. We introduced a new quantitative DSA parameter that can reflect the degree of intranidal blood stasis, called the lesion-filling index. MATERIALS AND METHODS This study examined patients with AVMs who had undergone both DSA and MR imaging between 2013 and 2014. Clinical presentations, angioarchitecture, and hemodynamic parameters generated from quantitative DSA were analyzed using univariate and multivariable logistic regression. The lesion-filling index was defined as the arterial diagnostic window divided by the volume of the AVM. To assess the correlation between the lesion-filling index and rupture, we incorporated the lesion-filling index into 2 published prediction models widely recognized for predicting AVM rupture risk, R2eD and VALE. The DeLong test was used to examine whether the addition of the lesion-filling index improved predictive efficacy. RESULTS A total of 180 patients with AVMs were included. The mean lesion-filling index values in the ruptured group were higher compared with the unruptured group (390.27 [SD, 919.81] versus 49.40 [SD, 98.25]), P < .001). A higher lesion-filling index was significantly correlated with AVM rupture in 3 different multivariable logistic models, adjusting for angioarchitecture factors (OR = 1.004, P = .02); hemodynamic factors (OR = 1.005, P = .009); and combined factors (OR = 1.004, P = .03). Both R2eD (area under the curve, 0.601 versus 0.624; P = .15) and VALE (area under the curve, 0.603 versus 0.706; P < .001) predictive models showed improved predictive performance after incorporating the lesion-filling index and conducting 10-fold cross-validation. CONCLUSIONS The lesion-filling index showed a strong correlation with AVM rupture, suggesting that overperfusion is the hemodynamic mechanism leading to AVM rupture.
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Affiliation(s)
- Ruinan Li
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (Y.C., X.C., Y.Z.), Beijing, China
- Beijing Neurosurgical Institute (Y.C., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pingting Chen
- College of Energy and Power Engineering (P.C.), Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Li Ma
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurological Surgery (L.M.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Heze Han
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wanting Zhou
- Department of Artificial Intelligence (W.Z.), Beijing University of Posts and Telecommunications, Beijing, China
| | - Xiaolin Chen
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (Y.C., X.C., Y.Z.), Beijing, China
- Beijing Neurosurgical Institute (Y.C., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- From the Department of Neurosurgery (R.L., Y.C., L.M., H.H., Z.L., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (Y.C., X.C., Y.Z.), Beijing, China
- Beijing Neurosurgical Institute (Y.C., X.C., Y.Z.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Luther E, McCarthy DJ, Burks J, Govindarajan V, Lu VM, Silva M, Lang M, Gross BA, Starke RM. National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence. J Neurointerv Surg 2023; 15:735-740. [PMID: 35902235 PMCID: PMC10306162 DOI: 10.1136/jnis-2022-019110] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recently, there has been a shift in management of unruptured cerebral arteriovenous malformations (AVMs) following studies suggesting that medical management alone was superior to interventional therapy. OBJECTIVE To evaluate the influence of contemporary AVM management on AVM rupture patterns in the United States. METHODS 154 297 AVM admissions were identified between 2003 and 2017 in the National Inpatient Sample. Annual AVM intervention and rupture rates were computed and multivariable logistic regression assessed the likelihood of AVM intervention pre- and post-2014. Segmented regression identified significant change points and fitted segmented linear models for annual intervention and rupture rates. Correlation coefficients assessed the relationship between annual AVM intervention and rupture rates. RESULTS For unruptured AVMs, intervention likelihood and proportion decreased after 2014 (28.1% to 22.3%, p<0.0001; adjusted OR=0.857, 95% CI 0.751 to 0.977, p=0.02). Ruptured AVM admissions increased from 14.7% to 18.6% after 2014 (p<0.0001). Between 2003 and 2017, segmented linear regression identified one significant change point in intervention rate between 2014 and 2015. Average annual percent change for rupture incidence and intervention rate increased by 0.49% (p=0.0001) and decreased by 1.17% (p=0.0001), respectively. Annual AVM intervention rates were inversely correlated with annual AVM rupture incidence (Pearson coefficient=-0.82, p=0.0002). In 2017, the annual AVM rupture rate (20.6%) surpassed the annual AVM intervention rate (19.7%). CONCLUSIONS After 2014, the likelihood of intervention for unruptured AVMs decreased while the incidence of ruptured AVMs increased. These findings suggest that fewer unruptured AVM treatments may lead to increases in AVM rupture incidence.
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Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Joshua Burks
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Vaidya Govindarajan
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Silva
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
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Vinchon M, Toubol A, Karnoub MA, Aboukais R, Leclerc X, Reyns N. Unruptured cerebral arteriovenous malformation in children: Outcome in treated and untreated patients. Neurochirurgie 2023; 69:101440. [PMID: 37060846 DOI: 10.1016/j.neuchi.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 03/21/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The management of unruptured cerebral arteriovenous malformation (URCAVM) is highly controversial; however, data regarding URCAVM in children are scarce. MATERIAL AND METHODS We retrospectively reviewed consecutive children followed for URCAVM in our department between 2001 and 2021. RESULTS Out of 36 patients, 12 were initially managed by observation, and 24 underwent first-line treatment: 8 by microsurgery, 10 by radiosurgery, 2 by embolization, and 4 by combined treatment. Mean follow-up of the whole group was 63months. Complete cure of the malformation was obtained in 14 patients (58%) in the treatment group: 8/8 in the microsurgery group, 5/10 in the radiosurgery group, 1/4 in the combined treatment group, and none in the embolization group. Two of the initially non-treated patients presented cerebral hemorrhage, with significant neurological consequences. In the treatment group, 5 patients presented new neurological deficits, only 1 of which, however, was functionally significant. Headache improved in 11 cases, mostly in the treatment group. Overall, 6 patients in the treatment group became asymptomatic, versus none in the observation group. CONCLUSIONS The treatment of URCAVM is a reasonable option in many pediatric cases, considering the cumulative risk of cerebral hemorrhage during the child's lifetime, as well as the symptoms specific to URCAVM. Microsurgery, when feasible, offers the best functional results and control of the AVM; however, the risk-benefit ratio should be weighed on a case-by-case basis. More studies will be needed to inform treatment decisions in pediatric URCAVM.
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Affiliation(s)
| | - Amelie Toubol
- Neurosurgery Clinic, Lille University Hospital, Lille, France
| | | | - Rabih Aboukais
- Neurosurgery Clinic, Lille University Hospital, Lille, France
| | - Xavier Leclerc
- Interventional Neuroradiology, Lille University Hospital, Lille, France
| | - Nicolas Reyns
- Neurosurgery Clinic, Lille University Hospital, Lille, France
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Quantitative evaluation of the hemodynamic differences between ruptured and unruptured cerebral arteriovenous malformations using angiographic parametric imaging-derived radiomics features. Neuroradiology 2023; 65:185-194. [PMID: 35922586 DOI: 10.1007/s00234-022-03030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 07/28/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Imaging features of cerebral arteriovenous malformations (AVMs) are mainly interpreted according to demographic and qualitative anatomical characteristics. This study aimed to use angiographic parametric imaging (API)-derived radiomics features to explore whether these features extracted from digital subtraction angiography (DSA) were associated with the hemorrhagic presentation of AVMs. METHODS Patients with AVM were retrospectively evaluated. Among them, 80% were randomly assigned to a training dataset, and the remaining 20% were assigned to an independent test dataset. Radiomics features were extracted from DSA by API. Then, informative features were selected from radiomics features and clinical features using the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm. A model was constructed based on the selected features to classify the dichotomous hemorrhagic presentation in the training dataset. The model performance was evaluated in the test dataset with confusion matrix-related metrics. RESULTS A total of 529 consecutive patients with AVMs between July 2011 and December 2020 were included in this study. After being selected by the LASSO algorithm and analyzed by multivariable logistic regression, three clinical features, namely, age (p = 0.01), nidus size (p < 0.001), and venous drainage patterns (p < 0.001), and four radiomics features were used to construct a model in the training dataset. On the independent test dataset, the model demonstrated a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.852, 0.844, 0.881, 0.809, and 0.849, respectively. CONCLUSION The radiomics features extracted from DSA by API could be potential indicators for the hemorrhagic presentation of AVMs.
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Lv X, Yu J, Zhao X, Zhang H, Zhang X. Is there an Influence of Match and Mismatch of Venous Drainage Pattern on AVM Hemorrhagic Presentation? Neurol India 2022; 70:1590-1592. [PMID: 36076663 DOI: 10.4103/0028-3886.355081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective To analyze whether there is an influence of match and mismatch of venous drainage patterns on arteriovenous malformation (AVM) hemorrhagic presentation. Methods Consecutive 161 patients of AVM between 2014 and 2017 were retrospectively reviewed. Venous drainage was considered deep or superficial. Match of venous drainage pattern was defined as a superficial AVM with only superficial venous drainage or a deep AVM with deep venous drainage. Mismatch of venous drainage pattern was defined as a superficial AVM involving a deep venous drainage. Univariate analysis was used to assess the influence of match and mismatch of venous drainage pattern on AVM hemorrhagic presentation. Results AVM location and venous drainage were matched in 116 patients, including superficial location with superficial venous drainage or deep location with deep venous drainage, and were mismatched in 45 patients, including superficial location with deep venous drainage. The rupture proportion of mismatch venous drainage pattern was statistically comparable to that of deep location with deep drainage (P = 0.819). However, superficial location with deep venous drainage was statistically associated with a higher rupture percentage than that of superficial location with superficial venous drainage (P = 0.003). Conclusions Mismatch venous drainage pattern or an exclusively deep venous drainage is associated with an initial clinical presentation with an AVM hemorrhage.
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Affiliation(s)
- Xianli Lv
- Department of Neurosurgical, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jianjun Yu
- Department of Neurosurgery, Linyi People Hospital, Weifang Medical University, Linyi, Shandong, China
| | - Xuelian Zhao
- Department of Neurosurgical, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huifang Zhang
- Department of Neurosurgical, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xinyan Zhang
- Department of Neurosurgical, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Cezayirli PC, Türe H, Türe U. Microsurgical Treatment of Deep and Eloquent AVMs. Adv Tech Stand Neurosurg 2022; 44:17-53. [PMID: 35107672 DOI: 10.1007/978-3-030-87649-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Over the past 30 years, the treatment of deep and eloquent arteriovenous malformations (AVMs) has moved away from microneurosurgical resection and towards medical management and the so-called minimally invasive techniques, such as endovascular embolization and radiosurgery. The Spetzler-Martin grading system (and subsequent modifications) has done much to aid in risk stratification for surgical intervention; however, the system does not predict the risk of hemorrhage nor risk from other interventions. In more recent years, the ARUBA trial has suggested that unruptured AVMs should be medically managed. In our experience, although these eloquent regions of the brain should be discussed with patients in assessing the risks and benefits of intervention, we believe each AVM should be assessed based on the characteristics of the patient and the angio-architecture of the AVM, in particular venous hypertension, which may guide us to treat even high-grade AVMs when we believe we can (and need to) to benefit the patient. Advances in imaging and intraoperative adjuncts have helped us in decision making, preoperative planning, and ensuring good outcomes for our patients. Here, we present several cases to illustrate our primary points that treating low-grade AVMs can be more difficult than treating high-grade ones, mismanagement of deep and eloquent AVMs at the behest of dogma can harm patients, and the treatment of any AVM should be tailored to the individual patient and that patient's lesion.
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Affiliation(s)
- Phillip Cem Cezayirli
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Hatice Türe
- Department of Anesthesiology, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey.
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Mamonov NA, Samochernykh KA. [Relationship between the features of venous drainage of supratentorial arteriovenous malformations and the risk of intracranial hemorrhage]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:104-108. [PMID: 35942844 DOI: 10.17116/neiro202286041104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Intracranial hemorrhage is the most common complication of cerebral arteriovenous malformations (AVM). In recent years, most studies devoted to the features of AVM functioning consider venous drainage as important factor influencing the rupture of malformation. OBJECTIVE To review the literature data on the relationship between the features of venous drainage of cerebral arteriovenous malformations and intracranial hemorrhage. MATERIAL AND METHODS We found 43 studies discussing the features of AVM venous drainage for the period from 1982 to 2020. Most of reports were published between 2005 and 2020. RESULTS Deep venous drainage and a single drainage vein were the most significant factors influencing the risk of hemorrhage. Venous ectasia, reflux, stenosis, number, length and tortuosity of drainage veins were less important for the risk of AVM rupture. CONCLUSION Analysis of the features of AVM venous drainage can make it possible to predict the natural course of disease and risk of intracranial hemorrhage. These aspects are essential for neurosurgical treatment.
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Affiliation(s)
- N A Mamonov
- Polenov Research Neurosurgical Institute, St. Petersburg, Russia
| | - K A Samochernykh
- Polenov Research Neurosurgical Institute, St. Petersburg, Russia
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Batista UC, Pereira BJA, Joaquim AF, Tedeschi H, Piske RL. Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 80:3-12. [PMID: 34932649 PMCID: PMC9651508 DOI: 10.1590/0004-282x-anp-2020-0291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/18/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. OBJECTIVE The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. METHODS A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). RESULTS A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). CONCLUSIONS Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.
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Affiliation(s)
- Ulysses Caus Batista
- Hospital Beneficência Portuguesa, Departamento de Neurorradiologia Intervencionista, São Paulo SP, Brazil.,Universidade Estadual de Campinas, Departamento de Neurocirurgia, Campinas SP, Brazil
| | | | | | - Helder Tedeschi
- Universidade Estadual de Campinas, Departamento de Neurocirurgia, Campinas SP, Brazil
| | - Ronie Leo Piske
- Hospital Beneficência Portuguesa, Departamento de Neurorradiologia Intervencionista, São Paulo SP, Brazil
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Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment. World Neurosurg 2021; 159:314-326. [PMID: 34339893 DOI: 10.1016/j.wneu.2021.07.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.
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Koch MJ, Bram R, Amin-Hanjani S. Commentary: Does Variceal Drainage Affect Arteriovenous Malformation Obliteration and Hemorrhage Rates After Stereotactic Radiosurgery? A Case-Matched Analysis. Neurosurgery 2021; 89:E219-E220. [PMID: 34318880 DOI: 10.1093/neuros/nyab281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew J Koch
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Richard Bram
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Lv X, Liang S. Update Onyx embolization for plexiform arteriovenous malformation: Ante-grade drifting technique. Neuroradiol J 2020; 33:386-392. [PMID: 32673165 PMCID: PMC7482047 DOI: 10.1177/1971400920940207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The conventional arteriovenous malformation (AVM) Onyx embolization technique is the extrusion Onyx injection technique, with blood-flow control after a certain distance casting through the head end of the microcatheter. This method has elevated periprocedural AVM bleeding complications. In this study, the authors reported safety and efficacy of an updated ante-grade drifting Onyx injection for plexiform AVM embolization. METHODS Between January 2016 and December 2018, 101 consecutive patients with plexiform AVMs were treated with ante-grade drifting Onyx injection. The patients' clinical status was classified using the modified Rankin Scale (mRS). To measure associations, logistic univariate or multivariate regression analyses were used. RESULTS Complete AVM obliteration was achieved in 51.2% (52/101) of patients. Two (2/101, 2.0%) arterial perforations occurred without causing neurological deficits. In univariate and multivariate logistic regression analyses, younger patient age (odds ratio (OR) = 1.06, 95% confidence interval (CI) 1.01-1.12, p = 0.014), haemorrhagic presentation at admission (OR = 7.14, 95% CI 1.52-33.33, p = 0.013) and low Spetzler-Martin grade (OR = 10.00, 95% CI 3.45-25.00, p < 0.001) were significantly correlated with complete obliteration. Pretreatment mRS was correlated with perforation complication (OR = 3.44, 95% CI 1.05-11.29, p = 0.041) in univariate logistic regression analysis but not in multivariate logistic regression analysis (OR = 2.956, 95%CI 0.745, 11.731, p = 0.123). Patients' clinical status was significantly improved after endovascular AVM embolization. CONCLUSIONS With ante-grade drifting Onyx injection, it was possible to prevent serious bleeding complications and elevated complete embolization rate in plexiform AVMs. Younger patient age, haemorrhagic presentation at admission and low AVM Spetzler-Martin grade were significantly correlated with complete obliteration. Although there is not enough statistical power to show that the pretreatment mRS and the arterial perforation complication have a significant correlation, but its OR value is large, and there may be more data in the future to obtain further conclusion.
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Affiliation(s)
- Xianli Lv
- Xianli Lv, Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Litang Road168, Changping, Beijing, 102218, PR China.
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Zhang S, Zhou C, Liu D, Piao Y, Zhang F, Hu J, Ma Z, Wei Z, Zhu W, Lv M. Is smoking a risk factor for bleeding in adult men with cerebral arteriovenous malformations? A single-center regression study from China. J Stroke Cerebrovasc Dis 2020; 29:105084. [PMID: 32807480 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 06/21/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess whether smoking increases the risk of bleeding in patients with cerebral arteriovenous malformations (CAVM). MATERIAL AND METHODS According to our research plan, 385 CAVM patients admitted to Beijing Tiantan Hospital from December 2015 to January 2018 were included in this study, including 210 bleeding patients and 175 non-bleeding patients. We divided patients into three subgroups of current smokers, ex-smokers (those who quit smoking for one year or more) and non-smokers. The relationship between smoking and the risk of CAVM rupture was assessed by univariate and multivariate regression analysis. RESULTS Multivariate regression analysis showed that there was a statistically significant difference between current smoker and non-smoker (OR = 1.87, p = 0.019). Among the covariates of the multivariate regression analysis, the location, combined with blood flow-related intracranial aneurysms and size were related to the risk of CAVM bleeding. CONCLUSION Current smoking may increase the risk of CAVM bleeding; however, there was no significant correlation between ex-smoking and CAVM bleeding.
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Affiliation(s)
- Shuai Zhang
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Chenguang Zhou
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, PR China
| | - Dong Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Centre for Neurological Diseases, Beijing, 100070, China
| | - Yongjun Piao
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Fuqiang Zhang
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Jie Hu
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Zongqian Ma
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Zhanyang Wei
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Weisheng Zhu
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China.
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing 100070, PR China.
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Alexander MD, Hippe DS, Cooke DL, Hallam DK, Hetts SW, Kim H, Lawton MT, Sekhar LN, Kim LJ, Ghodke BV. Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study. Neurosurgery 2019; 82:343-349. [PMID: 28419337 DOI: 10.1093/neuros/nyx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.
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Affiliation(s)
- Matthew D Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Daniel S Hippe
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Daniel L Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Danial K Hallam
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Steven W Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Helen Kim
- Univer-sity of California San Francisco, Depart-ment of Anesthesia and Perioperative Care, San Francisco, California
| | - Michael T Lawton
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Laligam N Sekhar
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
| | - Louis J Kim
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
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15
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Shaligram SS, Winkler E, Cooke D, Su H. Risk factors for hemorrhage of brain arteriovenous malformation. CNS Neurosci Ther 2019; 25:1085-1095. [PMID: 31359618 PMCID: PMC6776739 DOI: 10.1111/cns.13200] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with brain arteriovenous malformation (bAVM) are at risk of intracranial hemorrhage (ICH). Overall, bAVM accounts for 25% of hemorrhagic strokes in adults <50 years of age. The treatment of unruptured bAVMs has become controversial, because the natural history of these patients may be less morbid than invasive therapies. Available treatments include observation, surgical resection, endovascular embolization, stereotactic radiosurgery, or combination thereof. Knowing the risk factors for bAVM hemorrhage is crucial for selecting appropriate therapeutic strategies. In this review, we discussed several biological risk factors, which may contribute to bAVM hemorrhage.
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Affiliation(s)
- Sonali S Shaligram
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
| | - Ethan Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel Cooke
- Department of Radiology, University of California, San Francisco, California
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
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Abstract
Background and Purpose- The management of unruptured brain arteriovenous malformations remains unclear. Using a large cohort to determine risk factors predictive of hemorrhagic presentation of arteriovenous malformations, this study aims to develop a predictive tool that could guide hemorrhage risk stratification. Methods- A database of 789 arteriovenous malformation patients presenting to our institution between 1990 and 2017 was used. A hold-out method of model validation was used, whereby the data was randomly split in half into training and validation data sets. Factors significant at the univariable level in the training data set were used to construct a model based on multivariable logistic regression. Model performance was assessed using receiver operating curves on the training, validation, and complete data sets. The predictors and the complete data set were then used to derive a risk prediction formula and a practical scoring system, where every risk factor was worth 1 point except race, which was worth 2 points (total score varies from 0 to 6). The factors are summarized by R2eD arteriovenous malformation (acronym: R2eD AVM). Results- In 755 patients with complete data, 272 (36%) presented with hemorrhage. From the training data set, a model was derived containing the following risk factors: nonwhite race (odds ratio [OR]=1.8; P=0.02), small nidus size (OR=1.47; P=0.14), deep location (OR=2.3; P<0.01), single arterial feeder (OR=2.24; P<0.01), and exclusive deep venous drainage (OR=2.07; P=0.02). Area under the curve from receiver operating curve analysis was 0.702, 0.698, and 0.685 for the training, validation, and complete data sets, respectively. In the entire study population, the predicted probability of hemorrhagic presentation increased in a stepwise manner from 16% for patients with no risk factors (score of 0) to 78% for patients having all the risk factors (score of 6). Conclusions- The final model derived from this study can be used as a predictive tool that supplements clinical judgment and aids in patient counseling.
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Affiliation(s)
- James Feghali
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wuyang Yang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Risheng Xu
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jason Liew
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cameron G McDougall
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Justin M Caplan
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael J Tamargo
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Huang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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17
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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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18
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Pesce A, Frati A, D’Andrea G, Palmieri M, Familiari P, Cimatti M, Valente D, Raco A. The Real Impact of an Intraoperative Magnetic Resonance Imaging–Equipped Operative Theatre in Neurovascular Surgery: The Sapienza University Experience. World Neurosurg 2018; 120:190-199. [DOI: 10.1016/j.wneu.2018.08.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
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19
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Kocer N, Kandemirli SG, Dashti R, Kizilkilic O, Hanimoglu H, Sanus GZ, Tunali Y, Tureci E, Islak C, Kaynar MY. Single-stage planning for total cure of grade III-V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection. Neuroradiology 2018; 61:195-205. [PMID: 30488257 DOI: 10.1007/s00234-018-2140-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE There are no established guidelines for treatment of Spetzler-Martin grade III-V brain arteriovenous malformations (bAVMs). The purpose of this study is to report our institutional experience in total obliteration/eradication of grade III-V bAVMs by single-stage planning of embolization combined with microsurgical resection when necessary. METHODS All patients harboring Spetzler-Martin (S-M) grade III-V bAVMs treated with single-stage planning between January 2006 and January 2018 were retrospectively reviewed. This treatment paradigm is applicable only to surgically accessible bAVMs and does not include deep-seated bAVMs. Indications for treatment, clinical presentation, imaging characteristics, and treatment outcomes were analyzed. Outcomes were assessed based on modified Rankin Scale. RESULTS A total of 31 patients were identified. Seventeen patients (54.8%) presented with hemorrhage, 10 (32.3%) with seizures, 3 (9.7%) with headaches, and 1 (3.2%) with progressive neurological deficit. Based on S-M grading system, 25 patients (80.6%) harbored grade III bAVM, 5 patients had grade IV bAVMs (16.1%), and 1 patient (3.2%) had a grade V bAVM. There were no treatment-related complications in 24/31 (77.4%) patients. Of the total of seven patients with complications, four patients had clinical deterioration. The long-term (> 6-month), non-disabling morbidity (mRS ≤ 2) rate was 6.5%. The long-term, disabling morbidity rate was 3.2% with a mortality of 3.2%. Complete angiographic obliteration was achieved in 30/31 (96.8%) patients. CONCLUSION Single-stage treatment strategy can be considered as an alternative to multistage embolization prior to surgery in grade III-V bAVMs. In this study, a high rate of total obliteration with relatively low rates of permanent morbidity and mortality was achieved.
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Affiliation(s)
- Naci Kocer
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey.
| | - Sedat Giray Kandemirli
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Reza Dashti
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Osman Kizilkilic
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Hakan Hanimoglu
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yusuf Tunali
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ercan Tureci
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Mehmet Yasar Kaynar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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20
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Predictive variables for the presence of vascular malformations as the cause of basal ganglia hemorrhages. Neurosurg Rev 2018; 43:223-229. [DOI: 10.1007/s10143-018-1040-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/31/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
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21
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Endovascular Therapy for Brainstem Arteriovenous Malformations. World Neurosurg 2018; 125:481-488. [PMID: 30149173 DOI: 10.1016/j.wneu.2018.08.099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/21/2022]
Abstract
Brainstem arteriovenous malformations (AVMs) represent ∼5% of all intracranial AVMs and carry a higher risk of hemorrhage than their supratentorial counterparts. There is a high and near-uniform mortality with initial and recurrent episodes of hemorrhage. Brainstem AVMs may also present symptomatically with focal neurologic deficits or hydrocephalus. Treatment is indicated for ruptured and symptomatic brainstem AVMs, as well as those possessing high-risk angioarchitectural features. Microsurgical resection and stereotactic radiosurgery are ideal therapeutic options when feasible. Embolization is most commonly used as adjunctive treatment before surgery or stereotactic radiosurgical irradiation. Preoperative embolization facilitates microsurgical resection and reduces intraoperative and postoperative hemorrhage rates. Use of embolization preradiosurgically helps to reduce nidal size, transforming a large lesion to a size amenable to radiosurgical intervention, increasing the probability of obliteration, decreasing procedural hemorrhage risk, stabilizing the lesion until radiotherapeutic effect achieves obliteration, and providing interval symptomatic resolution. Embolization may also be used effectively as stand-alone monotherapy for small lesions with 1 or 2 arterial feeders not supplying eloquent parenchyma. Although an extensive evidence base exists for clinical usefulness of stereotactic radiosurgery as monotherapy or in combination with other therapeutic modalities, only a few studies have reported specifically on obliteration and complication rates with monotherapeutic embolization in the treatment of brainstem AVMs. The potential role of embolization as monotherapy for brainstem AVMs is reviewed and discussed.
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Hung AL, Yang W, Jiang B, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J. The Effect of Flow-Related Aneurysms on Hemorrhagic Risk of Intracranial Arteriovenous Malformations. Neurosurgery 2018; 85:466-475. [DOI: 10.1093/neuros/nyy360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/12/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Previous reports indicated an association between hemorrhagic presentation and flow-related aneurysms in arteriovenous malformation (AVM) patients. However, it remains unclear whether these flow-related aneurysms result in the hemorrhage of AVM.
OBJECTIVE
To characterize this hemorrhage risk using our institutional experience over 25 yr.
METHODS
We retrospectively reviewed records of patients at our institution diagnosed with AVM from 1990 to 2015. Patients without associated aneurysms (AVM only) and those with flow-related aneurysms (AVM-FA) were compared. Those with intranidal or unrelated aneurysms were excluded. Annual risk of AVM-related hemorrhage was calculated using the birth-to-treatment approach and compared using Poisson rate ratio test.
RESULTS
Among 526 patients, there were 457 AVM only patients and 69 with flow-related aneurysms. AVM-FA patients were older (P = .005). AVMs with flow-related aneurysms were more likely located in the cerebellar vermis and hemispheres (P = .023 and .001, respectively). Presence of flow-related aneurysms increased the risk of presentation with subarachnoid hemorrhage (P < .001). Interestingly, no significant differences in presenting hemorrhage due to AVM rupture were found (P > .356). The majority of aneurysms were untreated (69.5%), and only 8 (9.8%) had ruptured presentation. At follow-up (mean = 5.3 yr), patients with flow-related aneurysms were less likely to develop seizures (P = .004). The annual risk of AVM hemorrhage was 1.33% and 1.05% for AVM only patients and AVM-FA patients, respectively (P = .248).
CONCLUSION
Despite increased risk of subarachnoid hemorrhage at presentation, there was no increased likelihood of rupture in AVMs with flow-related aneurysms. More studies are warranted, as clarifying the competing risks of AVM vs aneurysm rupture may be critical in determining optimal treatment strategy.
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Affiliation(s)
- Alice L Hung
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Wuyang Yang
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Bowen Jiang
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
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Lv X, Wang G. Review of de novo cerebral arteriovenous malformation: haemorrhage risk, treatment approaches and outcomes. Neuroradiol J 2018; 31:224-229. [PMID: 29469668 PMCID: PMC5958505 DOI: 10.1177/1971400918759811] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective A small number of patients has been reported to develop a completely new or de novo arteriovenous malformation (AVM) after brain surgery, haemorrhage, head trauma or ischaemic stroke. The natural history of these lesions is unknown. In this review, both ruptured and unruptured de novo AVMs and their treatments were reviewed. Methods Published literature in the PubMed database citing 'de novo cerebral arteriovenous malformation' was reviewed. Additional studies were identified through reference searches in each reviewed article. A review was performed using all published cases, the treatment approaches and outcomes. Results A total of 38 patients, including 37 de novo AVMs reported from 1988 to 17 November 2017 and our one patient, was collected. The age at AVM diagnosis was 5-73 years (mean ± SD, 27.6 ± 20.5 years). The duration time, from negative examination to AVM diagnosis, was 2 months to 25 years (mean ± SD, 6.6 ± 4.9 years). The presentation of de novo AVM was headaches in three (7.9%) patients, bleedings in 12 (31.6%), incidental in 14 (36.8%) and seizure in nine (23.7%). The estimated risk of haemorrhage was 4.8% per year. Seventeen (44.7%) patients were treated with surgical resection, 10 (26.3%) were conservatively observed, nine (23.7%) were treated with radiosurgery and two (5.3%) were endovascularly embolised. The morbidity and mortality were reported as 5.3% and 7.9%, respectively. Conclusion Post-natal de novo AVMs have been reported. Their annual haemorrhage risk is 4.8%. Most of them are treated by surgical resection and are associated with morbidity and mortality.
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Affiliation(s)
| | - Guihuai Wang
- Guihuai Wang, Neurosurgery Department, Beijing Tsinghua Changgung Hospital, Tsinghua University, Changping, Litanglu 168, Beijing 102218, China.
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Jin H, Qiu H, Chen C, Ge H, Li Y, He H. Embolization of feeding arteries and symptom alleviation of mixed dural-pial arteriovenous malformations. Chin Neurosurg J 2018; 4:5. [PMID: 32922866 PMCID: PMC7393859 DOI: 10.1186/s41016-018-0111-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 02/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background To examine whether embolization of dural or pial blood supply branch is more efficient for symptom alleviation for unruptured mixed dural-pial arteriovenous malformations (DPAVMs). Methods We retrospectively reviewed 30 DPAVM patients from a database of 425 consecutive cerebral arteriovenous malformation (CAVM) patients who underwent endovascular embolization between January 2010 and December 2015 at our institution. Demographics, angioarchitectural characteristics, endovascular embolization details and patients clinical outcomes were recorded. The modified Rankin Scale (mRS), Engel‘s classification and Visual Analogue pain scale (VAS) were used to assess clinical outcomes. Results The single center cohort data shows that the incidence of DPAVM is 7.1%. Among the 30 DPAVM patients, 9 (30.0%) are ruptured and 21 (70.0%) are unruptured. Four (19.0%) of the 21 unruptured DPAVM patients are failed to follow-up, leaving 17 to analysis the clinical outcomes. Clinical presentations of the 17 unruptured DPAVM patients are epilepsy (n = 10), headache (n = 5) and focal neurological dysfunction (n = 2). Six patients have DPAVMs occluded via pial blood supply branches, 4 via dural branches and 7 via both pial and dural branches. Unruptured DPAVM patients with nidus occluded via dural blood supply branches, or both pial and dural branches have higher symptom alleviation rate than patients with nidus occluded via pial branches (100%/85.7% vs 66.7%). Conclusions For DPAVM patients presented with epilepsy, headache and FND, embolization via dural blood supply branches may be more efficient for symptom alleviation. Large cohort study is needed to confirm the generalizability.
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Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China
| | - Hong Qiu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China
| | - Chang Chen
- Neurosurgery Department, Xintai Hospital of Traditional Chinese Medicine, Tai'an, Shandong 271200 China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China.,Beijing Engineering Research Center for Interventional Neuroradiology, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China
| | - Hongwei He
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, Beijing 100050 China
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Yang W, Porras JL, Philadelphia E, Law J, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J. Treatment decision for occipital arteriovenous malformations (AVMs) to achieve hemorrhagic control while maximizing visual preservation: Our experience and review of literature. J Clin Neurosci 2017; 48:50-57. [PMID: 29113859 DOI: 10.1016/j.jocn.2017.10.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
Despite concern of hemorrhagic risk, patients with occipital AVMs are at significant risk for visual disturbances after treatment. We aim to characterize the hemorrhage risk and visual disturbance in occipital AVMs patients from our experience and literature review. We performed retrospective review of occipital AVM patients seen at our institution from 1990 to 2015. Patient characteristics were compared using multivariable logistic regression with follow-up visual disturbance as the outcome. We also systematically reviewed the PubMed database for English literature describing occipital AVMs (with exclusion of case reports). Ninety-seven patients satisfied inclusion criteria for our study. Mean age was 34.9 ± 16.4 years, with 50.5% male. Thirty-one (32.0%) presented with hemorrhage, and 32 (33.0%) presented with visual disturbance. Average AVM size was 4.0 ± 2.5 cm. Twenty-five (25.8%) were conservatively managed, 13 (13.4%) underwent surgery, and the rest were managed by radiosurgery (52.6%) or embolization (8.2%), with an obliteration rate of 38.9% in treated patients. During average follow-up of 5.4 years, 6 patients (6.7%) hemorrhaged yielding an annual hemorrhage rate of 1.2% for all patients, and 0.0% for surgically-treated patients. Thirty-seven (38.3%) patients experienced visual disturbance in some capacity, nineteen (21.1%) had de novo visual disturbance, fourteen of which were surgically treated patients (19.4%). Multivariable analysis reveals visual disturbance at presentation (p = .012) and microsurgery (p = .047) are significantly predictors of follow-up visual disturbance. While hemorrhage control remains the primary goal of AVM treatment, visual preservation in occipital AVMs is also a major concern. Recommending patients for microsurgery should be weighed carefully and individualized as it bears the highest risk of visual field disturbance despite most optimal hemorrhage control.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jose L Porras
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eunice Philadelphia
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jody Law
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Justin M Caplan
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Geoffrey P Colby
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alexander L Coon
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rafael J Tamargo
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Lv X, Song C, He H, Jiang C, Li Y. Transvenous retrograde AVM embolization: Indications, techniques, complications and outcomes. Interv Neuroradiol 2017; 23:504-509. [PMID: 28675345 PMCID: PMC5624411 DOI: 10.1177/1591019917716817] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Transvenous retrograde arteriovenous malformation (AVM) embolization (TRAE) has been proposed. The present study was to review the techniques, their conjunctions and effectiveness. Methods Eligible related articles were identified by searching the PubMed and Web of Science databases using "transvenous" and "arteriovenous malformation." Results A total of 16 eligible studies, with 60 cases of AVM treated with TRAE, were analyzed. Prior to TRAE procedure, transarterial Onyx 18 was performed in 23 (38.3%), cyanoacrylate in three (5%) and coiling in two (3.3%), neurosurgery in one (1.7%) and radiosurgery in three (5%). These prior treatments were used to reduce the size of the nidus to <3 cm and TRAE was performed. One anterior choroidal artery aneurysm was coiled before TRAE. Systemic hypotension (blood pressure<100 mmHg) occurred in six (10%) patients and local hypotension (proximal arterial temporary balloon protection) in five (8.3%) patients. Complete obliteration was achieved in 56 (93.3%) AVMs, four (6.7%) with residual, of which one was supplemented with radiosurgery. During mean one-year follow-up (1 month to 3.2 years), there were five cases (8.3%) of permanent disability and one (1.7%) mortality resulting from initial hemorrhage. Fifty-four (90%) patients were independent (mRS ≤ 2) at follow-up. Ruptured AVMs and Spetzler-Martin I-III were associated with a high cure rate. Conclusion According to previous reports, selected AVMs could undergo TRAE. TRAE is safe and curative with Onyx after the nidus size is reduced sufficiently by transarterial embolization, neurosurgery or radiosurgery, with or without the aid of proximal arterial temporary balloon protection.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Cao Song
- Neurosurgery Department, Jilin Center Hospital, People’s Republic of China
| | - Hongwei He
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Chuhan Jiang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Youxiang Li
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
- Youxiang Li, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Tiantan, Xili, 6, Dongcheng, Beijing, 100050, China.
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Lv X, Li W, He H, Jiang C, Li Y. Known and unknown cerebral arteriovenous malformations in pregnancies: haemorrhage risk and influence on obstetric management. Neuroradiol J 2017; 30. [PMID: 28635415 PMCID: PMC5602335 DOI: 10.1177/1971400917712264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective The objective of this study was to evaluate the haemorrhage risk of known and unknown cerebral arteriovenous malformations and their obstetric management. Methods A retrospective review was performed and analysed 67 consecutive cases of arteriovenous malformation with pregnancy history. Results Sixty-seven cases of arteriovenous malformation with pregnancy histories were identified. In 14 cases (20.9%) of arteriovenous malformation diagnosed before pregnancy, 11 cases were treated (10 embolisation and one surgery), there was no haemorrhage in 14 pregnancies, 14 healthy babies were delivered by caesarean section in 12 pregnancies (85.7%) and vaginal delivery in two pregnancies (14.3%). In 53 cases (89.1%) of arteriovenous malformation diagnosed during/after pregnancy, there was one (1.6%) case of subarachnoid haemorrhage at 38 weeks' gestation in 64 pregnancies, 64 healthy babies were delivered by caesarean section in 11 pregnancies (17.2%) and vaginal delivery in 53 pregnancies (82.8%). This resulted in 1.6% (95% confidence interval 0-4.6%) haemorrhage rate per pregnancy in unknown arteriovenous malformations. Known arteriovenous malformation gravida was prone to caesarean section; however, vaginal delivery did not increase the haemorrhage risk in unknown arteriovenous malformation gravidas (1.8% vs. 0%, P = 1.000). Conclusion Prior treatment for ruptured arteriovenous malformation could prevent its haemorrhage during pregnancy and the haemorrhage risk of unruptured arteriovenous malformation in pregnancies is low. Although known arteriovenous malformation gravida is prone to caesarean section, vaginal delivery seems not to increase the haemorrhage risk in unknown arteriovenous malformation gravidas.
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Affiliation(s)
| | | | | | | | - Youxiang Li
- Youxiang Li, Beijing Neurosurgerical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, Tiantan Xili, No. 6, Beijing, 100050, China.
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Critical review of brain AVM surgery, surgical results and natural history in 2017. Acta Neurochir (Wien) 2017; 159:1457-1478. [PMID: 28555270 DOI: 10.1007/s00701-017-3217-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND An understanding of the present standing of surgery, surgical results and the role in altering the future morbidity and mortality of untreated brain arteriovenous malformations (bAVMs) is appropriate considering the myriad alternative management pathways (including radiosurgery, embolization or some combination of treatments), varying risks and selection biases that have contributed to confusion regarding management. The purpose of this review is to clarify the link between the incidence of adverse outcomes that are reported from a management pathway of either surgery or no intervention with the projected risks of surgery or no intervention. METHODS A critical review of the literature was performed on the outcomes of surgery and non-intervention for bAVM. An analysis of the biases and how these may have influenced the outcomes was included to attempt to identify reasonable estimates of risks. RESULTS In the absence of treatment, the cumulative risk of future hemorrhage is approximately 16% and 29% at 10 and 20 years after diagnosis of bAVM without hemorrhage and 35% and 45% at 10 and 20 years when presenting with hemorrhage (annualized, this risk would be approximately 1.8% for unruptured bAVMs and 4.7% for 8 years for bAVMs presenting with hemorrhage followed by the unruptured bAVM rate). The cumulative outcome of these hemorrhages depends upon whether the patient remains untreated and is allowed to have a further hemorrhage or is treated at this time. Overall, approximately 42% will develop a new permanent neurological deficit or death from a hemorrhagic event. The presence of an associated proximal intracranial aneurysm (APIA) and restriction of venous outflow may increase the risk for subsequent hemorrhage. Other risks for increased risk of hemorrhage (age, pregnancy, female) were examined, and their purported association with hemorrhage is difficult to support. Both the Spetzler-Martin grading system (and its compaction into the Spetzler-Ponce tiers) and Lawton-Young supplementary grading system are excellent in predicting the risk of surgery. The 8-year risk of unfavorable outcome from surgery (complication leading to a permanent new neurological deficit with a modified Rankin Scale score of greater than one, residual bAVM or recurrence) is dependent on bAVM size, the presence of deep venous drainage (DVD) and location in critical brain (eloquent location). For patients with bAVMs who have neither a DVD nor eloquent location, the 8-year risk for an unfavorable outcome increases with size (increasing from 1 cm to 6 cm) from 1% to 9%. For patients with bAVM who have either a DVD or eloquent location (but not both), the 8-year risk for an unfavorable outcome increases with the size (increasing from 1 cm to 6 cm) from 4% to 35%. For patients with bAVM who have both a DVD and eloquent location, the 8-year risk for unfavorable outcome increases with size (increasing from 1 cm to 3 cm) from 12% to 38%. CONCLUSION Patients with a Spetzler-Ponce A bAVM expecting a good quality of life for the next 8 years are likely to do better with surgery in expert centers than remaining untreated. Ongoing research is urgently required on the outcome of management pathways for bAVM.
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Yang W, Porras JL, Xu R, Braileanu M, Khalid S, Hung AL, Caplan JM, Garzon-Muvdi T, Rong X, Colby GP, Coon AL, Tamargo RJ, Huang J. Comparison of Hemorrhagic Risk in Intracranial Arteriovenous Malformations Between Conservative Management and Embolization as the Single Treatment Modality. Neurosurgery 2017; 82:481-490. [DOI: 10.1093/neuros/nyx230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/10/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Embolization has been discussed as a feasible single modality treatment for intracranial arteriovenous malformations (AVMs).
OBJECTIVE
To compare hemorrhagic risk between embolization and conservative management in a multivariate survival analysis.
METHODS
We retrospectively reviewed records of patients with intracranial AVMs evaluated at our institution from 1990 to 2013. We included patients recommended to undergo embolization without other treatment modalities and patients managed conservatively. Multivariate Cox regression analysis of hemorrhage-free survival was performed, with the survival interval right-censored to date of either last follow-up or salvage treatment.
RESULTS
We identified 205 patients matching our inclusion criteria, with 160 patients in the noninterventional group and 45 in the embolization group. The average age of all patients was 40.2 ± 19.5 yr, with younger patients undergoing embolization more often (P = .026). Fifty-one (31.9%) conservatively managed patients and 13 (28.9%) patients treated by embolization (P = .703) presented with hemorrhage. Other baseline characteristics were similar between the 2 management groups. During an average follow-up period of 7.7 yr, 30 patients (14.6%) experienced hemorrhage recurrence. Multivariate Cox regression revealed older age (P = .031) and hemorrhagic presentation (P < .001) to be statistically associated with follow-up hemorrhage. In a subset analysis of unruptured AVMs, embolization was associated with a 4-fold hazard ratio of hemorrhage compared to conservative management (P = .044).
CONCLUSION
Older age and initial presentation with hemorrhage were associated with increased risk of hemorrhage during follow-up. Treatment of AVMs with embolization as the sole modality may increase hemorrhagic risk compared with conservative management, especially in unruptured AVMs.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria Braileanu
- Department of Internal Medicine, MedStar Georgetown University Hospital/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Syed Khalid
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaoming Rong
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
OBJECTIVE Brain arteriovenous malformation (AVM) rupture results in substantial morbidity and mortality. The goal of AVM treatment is eradication of the AVM, but the risk of treatment must be weighed against the risk of future hemorrhage. CONCLUSION Imaging plays a vital role by providing the information necessary for AVM management. Here, we discuss the background, natural history, clinical presentation, and imaging of AVMs. In addition, we explain advances in techniques for imaging AVMs.
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Osbun JW, Reynolds MR, Barrow DL. Arteriovenous malformations: epidemiology, clinical presentation, and diagnostic evaluation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:25-29. [PMID: 28552148 DOI: 10.1016/b978-0-444-63640-9.00003-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Brain arteriovenous malformations (AVMs) represent an uncommon disease of the central nervous system characterized by an arteriovenous shunt in which one or multiple arterial pedicles feed into a vascular nidus, creating early drainage into a venous outflow channel. These lesions are considered to be congenital and can come to clinical attention in a variety of ways such as seizure, intracranial hemorrhage, chronic headache or progressive neurological deficit. We focus on the epidemiology, clinical presentation and diagnostic evaluation in this chapter.
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Affiliation(s)
- Joshua W Osbun
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | | | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, GA, USA.
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Yang W, Porras JL, Hung AL, Khalid S, Garzon-Muvdi T, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Risk of hemorrhage in patients over age 60 with arteriovenous malformations (AVMs). J Clin Neurosci 2016; 34:121-127. [DOI: 10.1016/j.jocn.2016.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/18/2016] [Indexed: 01/01/2023]
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Yang W, Anderson-Keightly H, Westbroek EM, Caplan JM, Rong X, Hung AL, Colby GP, Coon AL, Tamargo RJ, Huang J, Ahn ES. Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations. J Neurosurg Pediatr 2016; 18:329-38. [PMID: 27153378 DOI: 10.3171/2016.3.peds15715] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Compared with the general population, the specific natural history of arteriovenous malformations (AVMs) in pediatric patients is less well understood. Furthermore, few pediatric studies have compared posttreatment hemorrhagic risk and functional outcome across different treatment modalities. The objective of this study was to elucidate these points. METHODS The authors retrospectively reviewed all pediatric patients with AVMs evaluated at their institution between 1990 and 2013. The AVM natural history was represented by hemorrhagic risk during the observation period. For treated patients, the observation period was defined as the interval between diagnosis and treatment. Posttreatment hemorrhagic risk and functional outcomes were also assessed. RESULTS A total of 124 pediatric patients with AVMs were evaluated, and 90 patients (72.6%) were retained through follow-up. The average patient age was 13.3 ± 3.8 years, with a mean follow-up period of 9.95 years. The overall AVM obliteration rate was 59.7%. Radiosurgery had an obliteration rate of 49.0%. Thirteen patients were managed conservatively. Four patients under observation hemorrhaged during a total interval of 429.4 patient-years, translating to an annual risk of 0.9%. Posttreatment hemorrhagic risk by treatment modalities were categorized as follows: surgery ± embolization (0.0%), radiosurgery ± embolization (0.8%), embolization alone (2.8%), surgery + radiosurgery ± embolization (3.5%), and observation (0.8%). A significantly higher risk of posttreatment hemorrhage was observed for patients with hemorrhagic presentation (p = 0.043) in multivariate analysis. Seizure presentation, frontal lobe location, nonheadache presentation, and treatment modality were significantly associated with increased risk of poor functional outcomes. CONCLUSIONS In this study of pediatric patients with AVMs, the natural history of hemorrhage was relatively low at 0.9%. Resection remained the optimal management for hemorrhage control and functional outcome perseverance in these pediatric patients with AVMs. AVM obliteration is a valid treatment goal, especially for patients with ruptured presentation, to prevent further hemorrhages later in life.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaoming Rong
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward S Ahn
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wang Q, Lin S, Dong W, Liu M. Characteristics of etiological diagnostic workup across the past 10 years in patients with spontaneous intracerebral hemorrhage in a large general hospital. Dev Neurorehabil 2016; 19:10-6. [PMID: 24483215 DOI: 10.3109/17518423.2013.878405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A swift and accurate diagnosis of etiology would lay the foundation of targeted management for patients with spontaneous intracerebral hemorrhage (SICH). It is unclear what the status of diagnostic workup related to etiology is in Chinese hospitals which treat the majority of the hemorrhagic patients in the world. We aim to demonstrate characteristics on diagnostic workup implemented routinely in both departments of Neurology and Neurosurgery in patients with SICH. METHODS We enrolled patients with SICH from March 2002 to December 2011 from Chengdu stroke registry. Data on diagnostic workup were extracted. RESULTS A total of 2264 patients diagnosed as SICH with rapid neuroimaging (computed tomography (CT) or magnetic resonance imaging (MRI)) scan were included. Patients in the department of Neurosurgery had a lower median Glasgow Coma Scale (GCS) score and a longer median length of stay. They had a significantly lower proportion of hyperlipidemia and heart disease, but a higher proportion of hypertension, alcohol consumption and history of stroke (all p < 0.05). Following diagnostic workups were more frequently undertaken in the Neurological Department than in the neurosurgical Department: digital subtraction angiography (DSA), plain CT, plain MRI, carotid duplex ultrasound (all p < 0.001). However, computed tomography angiography (CTA), contrast-enhanced MRI, and brain biopsy (all p < 0.001) were implemented more in the Neurosurgical Department. While no difference in the proportion of magnetic resonance angiography (MRA) was found between the two departments, the intracranial vascular imaging (workup contains at least one of CTA, MRA and DSA) was performed more frequently in the Department of Neurosurgery (29.8% vs. 9.1%, p < 0.001). The independent predictors contribute to the implementation of vascular examinations were gender, age, GCS score on admission, department of patients admitted in and the year patients were hospitalized in (all p < 0.05). CONCLUSIONS Younger patients, females, with severe stroke onset (evaluated by GCS score), admitted in Department of Neurosurgery and hospitalized in recent years had undertaken more examinations on intracranial vascular. It is an urgency to explore a practical scheme of diagnostic workup for the etiology of SICH.
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Affiliation(s)
- Qiuxiao Wang
- a Department of Neurology , West China Hospital, Sichuan University , Chengdu , People's Republic of China
| | - Sen Lin
- a Department of Neurology , West China Hospital, Sichuan University , Chengdu , People's Republic of China
| | - Wei Dong
- a Department of Neurology , West China Hospital, Sichuan University , Chengdu , People's Republic of China
| | - Ming Liu
- a Department of Neurology , West China Hospital, Sichuan University , Chengdu , People's Republic of China
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Fukuda K, Majumdar M, Masoud H, Nguyen T, Honarmand A, Shaibani A, Ansari S, Tan LA, Chen M. Multicenter assessment of morbidity associated with cerebral arteriovenous malformation hemorrhages. J Neurointerv Surg 2016; 9:664-668. [DOI: 10.1136/neurintsurg-2016-012485] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 05/28/2016] [Accepted: 06/01/2016] [Indexed: 11/03/2022]
Abstract
BackgroundThe optimal management strategy for unruptured cerebral arteriovenous malformations (AVMs) is controversial since the ARUBA trial (A Randomized trial of Unruptured Brain AVMs). An accurate understanding of the morbidity associated with AVM hemorrhages may help clinicians to formulate the best treatment strategy for unruptured AVMs.ObjectiveTo determine the morbidity associated with initial cerebral AVM rupture in patients presenting to tertiary medical centers.MethodsRetrospective chart reviews from three tertiary academic medical centers were performed for the period between 2008 and 2014. All patients admitted with intracranial hemorrhage due to untreated AVMs were included in this study. Patient-specific variables, including demographics, imaging characteristics, neurologic examination results, and clinical outcome, were analyzed and recorded.Results101 Patients met the inclusion criteria. Admission National Institutes of Health Stroke Scale (NIHSS) scores were 0, 1–9, and ≥10 in 26%, 29%, and 45% of patients, respectively. Hematoma locations were subarachnoid, intraventricular, intraparenchymal, and combined in 5%, 11%, 32%, and 52% of patients, respectively. Deep venous drainage was present in 43% of AVMs; AVM-associated aneurysms were present in 44% of patients. Emergent hematoma evacuations were performed in 37% of patients and 8% of patients died while in hospital. At discharge, of those who survived, NIHSS scores of ≥1 and ≥10 were found in 69% and 23%, respectively. At the 90-day follow-up, 34% had a modified Rankin Scale (mRS) score >2. Patients with admission NIHSS score ≥10 had significantly higher rates of midline shift, surgical hematoma evacuation, and follow-up mRS ≥3 (p<0.05).ConclusionsThe morbidity associated with cerebral AVM rupture appeared to be higher in our study than previously reported. Morbidity from AVM rupture should be considered as an important factor, together with variables such as risk of AVM rupture and procedural risk, in determining the optimal treatment strategy for unruptured cerebral AVMs.
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Alexander MD, Cooke DL, Hallam DK, Kim H, Hetts SW, Ghodke BV. Less can be more: Targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol 2016; 22:445-51. [PMID: 27066813 DOI: 10.1177/1591019916641316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To mitigate risks of hemorrhage, high-risk features of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of rupture. Previous investigation has examined embolization of a pedicle supplying a high-risk feature; this study examines embolization targeted specifically at aneurysms associated with BAVMs. MATERIALS AND METHODS Patients with BAVMs treated at two high-volume neurointerventional services were retrospectively reviewed. Patients treated with intention to occlude only the associated aneurysm itself were analyzed. Demographic and lesion characteristics were identified, as were technical and clinical outcomes. Adverse events were defined as hemorrhage, new seizure, and death. RESULTS Thirty-two patients met inclusion criteria out of 1103 patients treated during the study period. Twenty-seven (84.4%) BAVMs were acutely ruptured, all with the aneurysm identified as the hemorrhage source. Twenty-four (75.0%) lesions involved eloquent territory. There were equal numbers of feeding artery and nidus aneurysms. Follow-up data were available for a total of 101.3 patient-years for a mean follow-up time of 2.9 years. One patient died; the remaining 31 patients had improved functional status at last contact. Annualized rate of hemorrhage after treatment was 1.0%; rate of adverse events after treatment was 3.0%. Excluding time after confirmed occlusion following radiosurgery, annualized rates were 1.4% and 4.8%, respectively. CONCLUSION In inoperable BAVMs, targeted embolization of associated aneurysms can be performed safely and effectively. This should be considered in high-risk lesions prior to radiosurgery or in cases when no other treatment options are available. Such intervention warrants further investigation.
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Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | | | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California San Francisco, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
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Yang W, Hung AL, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Delayed Hemorrhage After Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2016; 87:98-109. [DOI: 10.1016/j.wneu.2015.11.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
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Dasenbrock HH, Du R. Presentation of Cerebral Arteriovenous Malformations. World Neurosurg 2016; 89:694-6. [PMID: 26739906 DOI: 10.1016/j.wneu.2015.11.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Hormuzdiyar H Dasenbrock
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Gruber A, Bavinzski G, Kitz K, Barthelmes S, Mayr M, Knosp E. Multimodality Management of Cerebral Arteriovenous Malformations with Special Reference to AVM-Related Hemorrhages During Ongoing Staged Treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 123:153-8. [PMID: 27637643 DOI: 10.1007/978-3-319-29887-0_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
In this study we report and analyze the results of a multimodality management concept for intracranial arteriovenous malformations (AVMs), including microsurgery, embolization, and gamma knife radiosurgery. The study population consists of a consecutive series of 294 patients treated for 304 intracranial AVMs over a 10-year period.
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Affiliation(s)
- Andreas Gruber
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | | | - Magdalena Mayr
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria.
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Yang W, Wei Z, Wang JY, Hung AL, Caplan JM, Braileanu M, Colby GP, Coon AL, Tamargo RJ, Huang J. Long-term Outcomes of Patients With Giant Intracranial Arteriovenous Malformations. Neurosurgery 2015; 79:116-24. [DOI: 10.1227/neu.0000000000001189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Giant intracranial arteriovenous malformations (AVMs) are rare cerebrovascular lesions that pose management challenges.
OBJECTIVE:
To further clarify outcomes in patients with giant cerebral AVMs managed with conservative or interventional therapies.
METHODS:
We performed a retrospective review of all patients diagnosed with AVMs evaluated at our institution from 1990 to 2013. Patients with a single intracranial AVM >6 cm were included. Patients were divided into 2 groups: conservative management or intervention (microsurgery, radiosurgery, or embolization). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups.
RESULTS:
A total of 55 patients with giant AVMs were included, and 35 patients (63.6%) had clinical follow-up with a mean of 11.8 years. Spetzler-Martin grades were as follows: grade III, n = 2 (3.6%); grade IV, n = 15 (27.3%); and grade V, n = 38 (69.1%). Twenty-four patients (43.6%) were conservatively managed. The patients in the conservatively managed group had larger AVMs (P < .05) with more frequent involvement of the temporal lobe (P = .02). Five patients (26.3%) in the conservatively managed group and 5 (31.3%) in the intervention group experienced hemorrhage during follow-up, translating to an annualized risk of 2.7% and 4.1%, respectively. No significant difference in risk of first subsequent hemorrhage was observed (P = .78). Despite comparable mRS scores at presentation, we observed a trend toward better outcomes (mRS < 2) in patients undergoing conservative management (P = .06) compared with the intervention group at last follow-up.
CONCLUSION
This study suggests that interventions for giant AVMs should be considered cautiously because hemorrhagic risk is similar regardless of management strategy and functional outcome is likely to be same or better in the conservatively managed population.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zhikui Wei
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanna Y. Wang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice L. Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M. Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria Braileanu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P. Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L. Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J. Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lv X, Liu J, Hu X, Li Y. Patient Age, Hemorrhage Patterns, and Outcomes of Arteriovenous Malformation. World Neurosurg 2015; 84:1039-44. [PMID: 26004700 DOI: 10.1016/j.wneu.2015.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/08/2015] [Accepted: 05/08/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The angioarchitecture and presentation of arteriovenous malformations (AVMs) associated with AVM hemorrhage may vary with patient age. Our aim was to determine the influence of patient age at diagnosis on hemorrhage patterns and outcomes. METHODS A consecutive case series of 267 cases of ruptured AVMs was retrospectively analyzed. Hemorrhage patterns (intracerebral hemorrhage, subarachnoid hemorrhage, and intraventricular hemorrhage) were confirmed based on computed tomography imaging at initial diagnosis. Clinical outcomes were classified with a modified Rankin Score. These cases were analyzed with respect to age at diagnosis, hemorrhage patterns, Spetzler-Martin grades, and their clinical outcomes. RESULTS During a mean 22.2 months follow-up time (range, 7 hours to 10 years), 212 cases (79.4%) were favorable (modified Rankin Score ≤2) and 55 cases (21.6%) were unfavorable (modified Rankin Score ≥3). The mean age was higher in patients with an unfavorable outcome at follow-up. In univariate analyses, different age groups were significantly associated with bleeding patterns (P = 0.022). Unfavorable outcome was associated with intracerebral hemorrhage (odds ratio, 0.330; 95% confidence interval, 0.142-0.768; P = 0.008) and evacuation of hematoma (odds ratio, 0.195; 95% confidence interval, 0.044-0.867; P = 0.025), whereas intraventricular hemorrhage, subarachnoid hemorrhage, and intraventricular drainage were significantly associated with a favorable outcome. Different age groups were not significantly associated with bleeding patterns, sex, and the location of the AVM, and Spetzler-Martin grades did not show a significant association with the severity of outcomes. CONCLUSIONS Different age groups were significantly associated with bleeding patterns. Higher patient age, intracerebral hemorrhage, and evacuation of hematoma seem to be associated with an unfavorable outcome after AVM rupture.
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Affiliation(s)
- Xianli Lv
- Interventional Neuroradiology Department, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Liu
- Interventional Neuroradiology Department, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiulan Hu
- Interventional Neuroradiology Department, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Interventional Neuroradiology Department, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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43
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Goyal N, Hoit D, Elijovich L. Spontaneous Thrombosis of a Ruptured Brain Arteriovenous Malformation: The Argument for Early Conservative Management. INTERVENTIONAL NEUROLOGY 2015; 3:122-8. [PMID: 26279658 DOI: 10.1159/000381035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Generally, definitive treatment of brain arteriovenous malformations (BAVM) presenting with hemorrhage is recommended to prevent recurrent hemorrhage. The risk of craniotomy and resection of BAVM has been well described using the Spetzler-Martin grading scale; however, the optimal timing for the definitive treatment of ruptured BAVM remains unclear. We report an interesting case of spontaneous BAVM thrombosis in which the patient presented with right occipital intracerebral hemorrhage caused by ruptured right occipital micro-BAVM. A preoperative angiogram 4 months later demonstrated spontaneous thrombosis of the AVM. Despite the risk of re-bleeding, the decision to defer treatment in the acute stage of illness in this case was based on the absence of high-risk angioarchitectural features in the arteriovenous malformations (AVM). It is important to emphasize the potential benefits of early conservative management, particularly in patients with low-risk angiographic features. We also review the literature of spontaneous BAVM thrombosis and discuss the potential benefit of early conservative management.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Sciences Center, Tenn., USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Tenn., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Sciences Center, Tenn., USA ; Department of Neurosurgery, University of Tennessee Health Sciences Center, Tenn., USA ; Department of Semmes-Murphey Neurologic and Spine Institute, Memphis, Tenn., USA
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Yang W, Caplan JM, Ye X, Wang JY, Braileanu M, Rigamonti D, Colby GP, Coon AL, Tamargo RJ, Huang J. Racial Associations with Hemorrhagic Presentation in Cerebral Arteriovenous Malformations. World Neurosurg 2015; 84:461-9. [DOI: 10.1016/j.wneu.2015.03.050] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
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Abstract
Cerebral arteriovenous malformation (AVM) in pregnancy is a complex situation and there is no agreement on its hemorrhage risk and treatment. Although studies on bleeding risk of cerebral AVMs in pregnancy are very few and there are different results between them, pregnancy will increase the hemorrhagic risk of AVM, and ruptured cerebral AVM in pregnancy should be treated actively. After intracranial hemorrhage, cerebral angiography should be performed for pregnant women shielded correctly. Cerebral angiography could clearly demonstrate the characteristics of cerebral AVM. The results from the literature show that the radiation dose of endovascular and stereotactic radiotherapy for cerebral AVM in pregnancy is below the safety value and is safe. Unruptured AVM in pregnancy, if there is no bleeding factor, such as no coexisting aneurysm, smooth venous drainage, no venous ectasia, or high risk of treatment, should be observed conservatively.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
| | - Youxiang Li
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
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Abstract
Cerebral arteriovenous malformation (AVM) in pregnancy is a complex situation and there is no agreement on its hemorrhage risk and treatment. Although studies on bleeding risk of cerebral AVMs in pregnancy are very few, and they provide different results, pregnancy will increase the hemorrhagic risk of AVM and ruptured cerebral AVM in pregnancy should be actively treated. After intracranial hemorrhage, cerebral angiography should be performed for pregnant women shielded correctly. Cerebral angiography could clearly demonstrate the characteristics of cerebral AVM. Results from the literature show that the radiation dose of endovascular and stereotactic radiotherapy for cerebral AVM in pregnancy was below the safety value and was safe. For an unruptured AVM in pregnancy, if there are no bleeding factors, e.g. no coexisting aneurysm, smooth venous drainage, no venous ectasia, or high risk of treatment, then it should be observed conservatively.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
| | - Peng Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
| | - Youxiang Li
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China
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47
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Alexander MD, Cooke DL, Nelson J, Guo DE, Dowd CF, Higashida RT, Halbach VV, Lawton MT, Kim H, Hetts SW. Association between Venous Angioarchitectural Features of Sporadic Brain Arteriovenous Malformations and Intracranial Hemorrhage. AJNR Am J Neuroradiol 2015; 36:949-52. [PMID: 25634722 DOI: 10.3174/ajnr.a4224] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/21/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage is the most serious outcome for brain arteriovenous malformations. This study examines associations between venous characteristics of these lesions and intracranial hemorrhage. MATERIALS AND METHODS Statistical analysis was performed on a prospectively maintained data base of brain AVMs evaluated at an academic medical center. DSA, CT, and MR imaging studies were evaluated to classify lesion side, drainage pattern, venous stenosis, number of draining veins, venous ectasia, and venous reflux. Logistic regression analyses were performed to identify the association of these angiographic features with intracranial hemorrhage of any age at initial presentation. RESULTS Exclusively deep drainage (OR, 3.42; 95% CI, 1.87-6.26; P < .001) and a single draining vein (OR, 1.98; 95% CI, 1.26-3.08; P = .002) were associated with hemorrhage, whereas venous ectasia (OR, 0.52; 95% CI, 0.34-0.78; P = .002) was inversely associated with hemorrhage. CONCLUSIONS Analysis of venous characteristics of brain AVMs may help determine their prognosis and thereby identify lesions most appropriate for treatment.
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Affiliation(s)
- M D Alexander
- From the Department of Radiology (M.D.A.), University of Washington, Seattle, Washington
| | - D L Cooke
- Department of Radiology and Biomedical Imaging (D.L.C., C.F.D., R.T.H., V.V.H., S.W.H.)
| | - J Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (J.N., D.E.G., H.K.)
| | - D E Guo
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (J.N., D.E.G., H.K.)
| | - C F Dowd
- Department of Radiology and Biomedical Imaging (D.L.C., C.F.D., R.T.H., V.V.H., S.W.H.)
| | - R T Higashida
- Department of Radiology and Biomedical Imaging (D.L.C., C.F.D., R.T.H., V.V.H., S.W.H.)
| | - V V Halbach
- Department of Radiology and Biomedical Imaging (D.L.C., C.F.D., R.T.H., V.V.H., S.W.H.)
| | - M T Lawton
- Department of Neurological Surgery (M.T.L.), University of California, San Francisco, San Francisco, California
| | - H Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care (J.N., D.E.G., H.K.)
| | - S W Hetts
- Department of Radiology and Biomedical Imaging (D.L.C., C.F.D., R.T.H., V.V.H., S.W.H.)
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Majumdar M, Tan LA, Chen M. Critical assessment of the morbidity associated with ruptured cerebral arteriovenous malformations. J Neurointerv Surg 2015; 8:163-7. [PMID: 25568227 DOI: 10.1136/neurintsurg-2014-011517] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/07/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND An accurate understanding of the morbidity and mortality associated with brain arteriovenous malformation (AVM) hemorrhage is important in determining the management of unruptured AVMs. Recent studies suggest this morbidity to be lower than assumed. We sought to perform a detailed critical assessment of the morbidity associated with ruptured brain AVMs. METHODS A retrospective chart review from a single-center tertiary care medical center was performed. Inclusion criteria were patients admitted with intracranial hemorrhage caused by a previously untreated AVM. Forty variables were analyzed including patient demographics, imaging findings, clinical course, and clinical examinations. RESULTS From 2008 to 2013, of the 51 patients who fit our inclusion criteria, we found admission National Institutes of Health Stroke Scale (NIHSS) scores of 0, 1-9, and ≥10 in 22%, 24%, and 55%, respectively. Hematoma location was parenchymal in 33%, intraventricular in 10%, subarachnoid in 4%, and combined in 53%. Deep venous drainage was present in 35% of cases and associated aneurysms were present in 37%. 43% underwent emergency hematoma evacuation while four patients died during their admission. Of those who survived, 74% had neurologic deficits upon discharge (NIHSS ≥1), with 25.5% of patients having a severe deficit (NIHSS ≥10). On follow-up, 55% were independent in their daily activities of living. CONCLUSIONS Our assessment of morbidity associated with brain AVM rupture is higher than previously assumed and reported. These results should be further validated in a larger, more representative sample. An accurate understanding of the morbidity associated with AVM rupture is important as more patients with unruptured brain AVMs seek consultation.
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Affiliation(s)
| | - Lee A Tan
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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KELLNER CHRISTOPHERP, MCDOWELL MICHAELM, PHAN MICHELLEQ, CONNOLLY ESANDER, LAVINE SEAND, MEYERS PHILIPM, SAHLEIN DANIEL, SOLOMON ROBERTA, FELDSTEIN NEILA, ANDERSON RICHARDCE. Number and location of draining veins in pediatric arteriovenous malformations: association with hemorrhage. J Neurosurg Pediatr 2014; 14:538-45. [PMID: 25238624 PMCID: PMC9879622 DOI: 10.3171/2014.7.peds13563] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECT The significance of draining vein anatomy is poorly defined in pediatric arteriovenous malformations (AVMs). In adult cohorts, the presence of fewer veins has been shown to lead to an increased rate of hemorrhage, but this phenomenon has not yet been studied in pediatric AVMs. This report analyzes the impact of draining vein anatomy on presentation and outcome in a large series of pediatric AVMs. METHODS Eighty-five pediatric patients with AVMs were treated at the Columbia University Medical Center between 1991 and 2012. Charts were retrospectively reviewed for patient characteristics, clinical course, neurological outcome, and AVM angioarchitectural features identified on the angiogram performed at presentation. Univariate analyses were performed using chi-square test and ANOVA when appropriate; multivariate analysis was performed using logistic regression. RESULTS Four patients were excluded due to incomplete records. Twenty-seven patients had 2 or 3 draining veins; 12 (44.4%) of these patients suffered from hemorrhage prior to surgery. Fifty-four patients had 1 draining vein; 39 (72.2%) of these 54 suffered from hemorrhage. Independent predictors of hemorrhage included the presence of a single draining vein (p = 0.04) and deep venous drainage (p = 0.02). Good outcome (modified Rankin Scale [mRS] score < 3) on discharge was found to be associated with higher admission Glasgow Coma Scale (GCS) scores (p = 0.0001, OR 0.638, 95% CI 0.40-0.93). Poor outcome (mRS score > 2) on discharge was found to be associated with deep venous drainage (p = 0.04, OR 4.68, 95% CI 1.1-19.98). A higher admission GCS score was associated with a lower discharge mRS score (p = 0.0003, OR 0.6, 95% CI 0.46-0.79), and the presence of a single draining vein was associated with a lower mRS score on long-term follow-up (p = 0.04, OR 0.18, 95% CI 0.032-0.99). CONCLUSIONS The authors' data suggest that the presence of a single draining vein or deep venous drainage plays a role in hemorrhage risk and ultimate outcome in pediatric AVMs. Small AVMs with a single or deep draining vein may have the highest risk of hemorrhage.
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Meling TR, Proust F, Gruber A, Niemela M, Regli L, Roche PH, Vajkoczy P. On apples, oranges, and ARUBA. Acta Neurochir (Wien) 2014; 156:1775-9. [PMID: 24890935 DOI: 10.1007/s00701-014-2140-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Torstein R Meling
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, 0027, Norway,
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