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Chen S. Letter: Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 95:e54. [PMID: 38869299 DOI: 10.1227/neu.0000000000003044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 06/14/2024] Open
Affiliation(s)
- Shaopeng Chen
- Department of Surgery, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi , Hubei , China
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2
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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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3
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Kim MJ, Jung HH, Kim YB, Chang JH, Chang JW, Park KY, Chang WS. Comparison of Single-Session, Neoadjuvant, and Adjuvant Embolization Gamma Knife Radiosurgery for Arteriovenous Malformation. Neurosurgery 2022; 92:986-997. [PMID: 36700732 DOI: 10.1227/neu.0000000000002308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The purpose of intracranial arteriovenous malformations (AVMs) treatment is to prevent bleeding or subsequent hemorrhage with complete obliteration. For large, difficult-to-treat AVMs, multimodal approaches including surgery, endovascular embolization, and gamma knife radiosurgery (GKRS) are frequently used. OBJECTIVE To analyze the outcomes of AVMs treated with single-session, neoadjuvant, and adjuvant embolization GKRS. METHODS We retrospectively reviewed a database of 453 patients with AVMs who underwent GKRS between January 2007 and December 2017 at our facility. The obliteration rate, incidence of latent period bleeding, cyst formation, and radiation-induced changes were compared among the 3 groups, neoadjuvant-embolized, adjuvant-embolized, nonembolized group. In addition, the variables predicting AVM obliteration and complications were investigated. RESULTS A total of 228 patients were enrolled in this study. The neoadjuvant-embolized, adjuvant-embolized, and nonembolized groups comprised 29 (12.7%), 19 (8.3%), and 180 (78.9%) patients, respectively. Significant differences were detected among the 3 groups in the history of previous hemorrhage and the presence of aneurysms ( P < .0001). Multivariate Cox regression analyses revealed a significant inverse correlation between neoadjuvant embolization and obliteration occurring 36 months after GKRS (hazard ratio, 0.326; P = .006). CONCLUSION GKRS with either neoadjuvant or adjuvant embolization is a beneficial approach for the treatment of AVMs with highly complex angioarchitectures that are at risk for hemorrhage during the latency period. Embolization before GKRS may be a negative predictive factor for late-stage obliteration (>36 months). To confirm our conclusions, further studies involving a larger number of patients and continuous follow-up are necessary.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University College of Medicine, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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4
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Chang H, Silva MA, Weng J, Kovacevic J, Luther E, Starke RM. The impact of embolization on radiosurgery obliteration rates for brain arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:28. [PMID: 36576595 DOI: 10.1007/s10143-022-01935-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 11/25/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
There exists no consensus in the literature regarding the impact of pre-stereotactic radiosurgery (SRS) embolization on obliteration rates and clinical outcome after radiosurgery treatment of intracranial arteriovenous malformations (AVM). We performed a systematic review of four databases and included studies with at least 10 patients evaluating obliteration rates of intracranial AVMs treated with SRS alone (SRS cohort) and combined pre-SRS embolization followed by SRS (E + SRS cohort). Meta-analytic results were pooled together via random-effects models. A total of 43 studies, with 7103 patients, were included in our analysis. Among our included patients, complete obliteration was achieved in 51.5% (964/1871) of patients in the E + SRS cohort as compared to 61.5% (3217/5231) of patients in the SRS cohort. Meta-analysis of the pooled data revealed that obliteration was significantly lower in the E + SRS cohort (pooled OR = 0.64, 95% CI = 0.54-0.75, p < 0.0001). The use of pre-SRS embolization was significantly associated with lower AVM obliteration rates when compared to treatment with SRS alone. Our analysis seeks to provide a macroscopic insight into the complex interaction between pre-SRS embolization and brain AVM obliteration rates and prognosis. Pre-SRS embolization may still be beneficial in select patients, and further studies are needed to identify patients who benefit from neoadjuvant AVM embolization.
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Affiliation(s)
- Henry Chang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA.
| | - Michael A Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - John Weng
- Florida State University College of Medicine, Tallahassee, FL, USA
| | | | - Evan Luther
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
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5
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Saggi S, Winkler EA, Ammanuel SG, Morshed RA, Garcia JH, Young JS, Semonche A, Fullerton HJ, Kim H, Cooke DL, Hetts SW, Abla A, Lawton MT, Gupta N. Machine learning for predicting hemorrhage in pediatric patients with brain arteriovenous malformation. J Neurosurg Pediatr 2022; 30:203-209. [PMID: 35916099 DOI: 10.3171/2022.4.peds21470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ruptured brain arteriovenous malformations (bAVMs) in a child are associated with substantial morbidity and mortality. Prior studies investigating predictors of hemorrhagic presentation of a bAVM during childhood are limited. Machine learning (ML), which has high predictive accuracy when applied to large data sets, can be a useful adjunct for predicting hemorrhagic presentation. The goal of this study was to use ML in conjunction with a traditional regression approach to identify predictors of hemorrhagic presentation in pediatric patients based on a retrospective cohort study design. METHODS Using data obtained from 186 pediatric patients over a 19-year study period, the authors implemented three ML algorithms (random forest models, gradient boosted decision trees, and AdaBoost) to identify features that were most important for predicting hemorrhagic presentation. Additionally, logistic regression analysis was used to ascertain significant predictors of hemorrhagic presentation as a comparison. RESULTS All three ML models were consistent in identifying bAVM size and patient age at presentation as the two most important factors for predicting hemorrhagic presentation. Age at presentation was not identified as a significant predictor of hemorrhagic presentation in multivariable logistic regression. Gradient boosted decision trees/AdaBoost and random forest models identified bAVM location and a concurrent arterial aneurysm as the third most important factors, respectively. Finally, logistic regression identified a left-sided bAVM, small bAVM size, and the presence of a concurrent arterial aneurysm as significant risk factors for hemorrhagic presentation. CONCLUSIONS By using an ML approach, the authors found predictors of hemorrhagic presentation that were not identified using a conventional regression approach.
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Affiliation(s)
- Satvir Saggi
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Simon G Ammanuel
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Joseph H Garcia
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Jacob S Young
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Alexa Semonche
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Heather J Fullerton
- 2Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco
| | - Helen Kim
- 3Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco
| | - Daniel L Cooke
- 4Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Steven W Hetts
- 4Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Adib Abla
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Michael T Lawton
- 5Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California, San Francisco.,6Department of Pediatrics, University of California, San Francisco, California
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6
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Curative Embolization for Pediatric Spetzler-Martin Grade III Cerebral Arteriovenous Malformations. World Neurosurg 2022; 160:e494-e500. [PMID: 35074545 DOI: 10.1016/j.wneu.2022.01.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) represent a gray zone due to their high variability in location, size, and angioarchitecture. In addition, there is a lack of information on curative embolization in the pediatric population, especially in this subgroup of lesions. Here we present our experience treating grade III AVMs by curative embolization in pediatric patients. METHODS Clinical and angiographic data from pediatric patients with grade III SM AVMs were retrospectively collected between 2011 and 2020 in a referral institution. We grouped the AVMs into subtypes according to size (S), venous drainage (V), and eloquence (E) and obtained subtypes: IIIA (S1V1E1), IIIB (S2V1E0), IIIC (S2V0E1), and IIID (S3V0E0). RESULTS A total of 61 embolization sessions were performed in 35 pediatric patients. There were 25 females (64%), and the mean age was 12.2 years (range 5-18). Complete angiographic occlusion was achieved in 16 patients (47%). In 13 patients (37%), the AVM was occluded with a single embolization session and most (12/13) had small lesions (IIIA subtype). Among the 19 patients with incomplete occlusion, most (58%) had large lesions (IIIB, IIIC, and IIID). Large AVMs (IIIB, IIIC, and IIID) underwent 36 sessions; however, only 3 patients (21%) achieved complete occlusion in 11 sessions. Eight intraoperative complications (13% procedures) occurred mainly in ruptured AVMs (7/8) and eloquent zones (7/8). CONCLUSIONS Curative embolization for SM grade III AVMs in children carries a high complication rate, especially in small, ruptured, and eloquent lesions. In addition, acceptable immediate complete angiographic occlusion rates were achieved, especially in small AVMs.
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Lim JX, Cheong TM, Ng LP, Seow WT, Chua FHZ, Kirollos RW, Low DCY, Low SYY. Paediatric Cerebral Arteriovenous Malformation: Outcomes from a Singapore Children's Hospital. J Stroke Cerebrovasc Dis 2022; 31:106283. [PMID: 34998042 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106283] [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: 10/18/2021] [Revised: 11/22/2021] [Accepted: 12/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Paediatric brain arteriovenous malformation (bAVM) is a rare and distinct clinical entity. There is a growing body of literature that support the success of multimodality approaches for this difficult condition. The authors aim to firstly, describe our institutional experience with a consecutive series of patients and next, corroborate our results with current literature. MATERIAL AND METHODS This is a single institution, retrospective study conducted over a 20-year period. Patients less than 19 years old with bAVM were included. Variables of interest included patient demographics, clinical presentation, neuroimaging features, bAVM characteristics and treatment modality. Functional outcomes were measured with modified Rankin scale (mRS). RESULTS There were 58 paediatric bAVMs, presenting at a mean age of 8.7 ± 4.2 years, and followed up for a mean duration of 7.7 years. Thirty-six patients (62.1%) underwent microsurgical resection, 10 patients had stereotactic radiosurgery (17.2%) and 2 patients had endovascular treatment (3.4%). 50 patients (86.2%) had a favourable outcome at 1-year follow up. Microsurgical resection and SRS had similar obliteration rates (resection 83.3%; SRS 80.0%) and recurrence (resection 10.0%; SRS 12.5%). There were 6 cases of bAVM recurrence (12.8%). This subgroup was noted to be less than 7.5 years old at presentation (OR 15.0, 95% CI 1.56 - 144), and less likely to present with bAVM rupture (OR 0.11, 95% CI 0.01 - 0.96). CONCLUSION This study describes our experience in managing paediatric bAVM, whereby monomodal therapy can still be effective. Of note, we also demonstrate the role of extended surveillance to detect recurrence.
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Affiliation(s)
- Jia Xu Lim
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899 Singapore
| | - Tien Ming Cheong
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899 Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899 Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433 Singapore
| | | | - Ramez Wadie Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433 Singapore
| | - David Chyi Yeu Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899 Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433 Singapore
| | - Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899 Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433 Singapore.
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8
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Hak JF, Boulouis G, Kerleroux B, Benichi S, Stricker S, Gariel F, Garzelli L, Meyer P, Kossorotoff M, Boddaert N, Vidal V, Girard N, Dangouloff-Ros V, Brunelle F, Fullerton H, Hetts SW, Blauwblomme T, Naggara O. Pediatric brain arteriovenous malformation recurrence: a cohort study, systematic review and meta-analysis. J Neurointerv Surg 2021; 14:611-617. [PMID: 34583986 DOI: 10.1136/neurintsurg-2021-017777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/31/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recurrence following obliteration of brain arteriovenous malformations (AVMs) is common in children surgically treated, but recurrences following endovascular (EVT) and radiosurgical approaches are scantily reported. OBJECTIVE To analyze the rates and risk factors for AVM recurrence after obliteration in a single-center cohort of children with ruptured AVMs treated with multimodal approaches, and to carry out a comprehensive review and meta-analysis of current data. METHODS Children with ruptured AVMs between 2000 and 2019 enrolled in a prospective registry were retrospectively screened and included after angiographically determined obliteration to differentiate children with/without recurrence. A complementary systematic review and meta-analysis of studies investigating AVM recurrence in children between 2000 and 2020 was aggregated to explore the overall recurrence rates across treatment modalities by analyzing surgery versus other treatments. RESULTS Seventy children with obliterated AVMs were included. AVM recurrences (n=10) were more commonly treated with EVT as final treatment (60% in the recurrence vs 13.3% in the no-recurrence group, p=0.018). Infratentorial locations were associated with earlier and more frequent recurrences (adjusted relative risk=4.62, 95% CI 1.08 to 19.04; p=0.04).In the aggregate analysis, the pooled rate of AVM recurrence was 10.9% (95% CI 8.7% to 13.5%). Younger age at presentation was associated with more frequent recurrences (RR per year increase, 0.97, 95% CI 0.93 to 0.99; p=0.046). CONCLUSION Location of infratentorial AVMs and younger age at presentation may be associated with earlier and more frequent recurrences. The higher rates of recurrence in patients with AVMs obliterated with EVT questions its role in an intent-to-cure approach and reinforces its position as an adjunct to surgery and/or radiosurgery.
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Affiliation(s)
- Jean-Francois Hak
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France .,Department of Neuroradiology, INSERM UMR 1266 IMA-BRAIN, GHU Paris, Paris, France
| | - Gregoire Boulouis
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France.,Department of Neuroradiology, INSERM UMR 1266 IMA-BRAIN, GHU Paris, Paris, France
| | - Basile Kerleroux
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France.,Department of Neuroradiology, INSERM UMR 1266 IMA-BRAIN, GHU Paris, Paris, France
| | - Sandro Benichi
- Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163, APHP, Necker Sick Children Hospital, Paris, France
| | - Sarah Stricker
- Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163, APHP, Necker Sick Children Hospital, Paris, France
| | - Florent Gariel
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France.,Department of Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Lorenzo Garzelli
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France
| | - Philippe Meyer
- Department of Pediatric Neuro ICU, APHP, Necker Sick Children Hospital, Paris, France
| | - Manoelle Kossorotoff
- Department of Pediatric Neurology, APHP University Necker Children Hospital, Paris, France.,French Center for Pediatric Stroke, INSERM U894, APHP, Necker Sick Children Hospital, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France
| | - Vincent Vidal
- Department of Radiology, University Hospital La Timone, AP-HM, Marseille, France
| | - Nadine Girard
- Department of Neuroradiology, University Hospital La Timone, AP-HM, Marseille, France
| | - Volodia Dangouloff-Ros
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France
| | - Francis Brunelle
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France
| | - Heather Fullerton
- Department of Neurology, University of California San Francisco, San Francisco, California, USA.,Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Thomas Blauwblomme
- Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163, APHP, Necker Sick Children Hospital, Paris, France.,French Center for Pediatric Stroke, INSERM U894, APHP, Necker Sick Children Hospital, Paris, France
| | - Olivier Naggara
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France.,Department of Neuroradiology, INSERM UMR 1266 IMA-BRAIN, GHU Paris, Paris, France.,French Center for Pediatric Stroke, INSERM U894, APHP, Necker Sick Children Hospital, Paris, France
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9
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Lauzier DC, Vellimana AK, Chatterjee AR, Osbun JW, Moran CJ, Zipfel GJ, Kansagra AP. Return of the lesion: a meta-analysis of 1134 angiographically cured pediatric arteriovenous malformations. J Neurosurg Pediatr 2021:1-8. [PMID: 34507285 DOI: 10.3171/2021.6.peds21227] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) carry a risk of rupture and subsequent morbidity or mortality unless fully treated. AVMs in pediatric patients are known to occasionally recur after obliteration. The objective of this study was to characterize the risk of AVM recurrence following angiographically confirmed obliteration in children. METHODS Consecutive pediatric AVMs treated at a single center were identified from a prospective database. Patients with angiographically confirmed AVM obliteration following treatment were included in this study. Associations between AVM recurrence and patient or procedural factors were characterized using the two-tailed Fisher exact test or Mann-Whitney U-test. A literature search was conducted using PubMed, Scopus, Embase, and the Clarivate Web of Science with defined search criteria, and eligible studies were included alongside this study cohort in a meta-analysis. Rates of AVM recurrence following obliteration were pooled across studies with a random-effects model and reported with 95% confidence intervals (CIs). RESULTS Recurrence after angiographic confirmation of AVM obliteration was observed in 10.4% (7/67) of pediatric AVMs treated at the authors' center. Patients with recurrent AVMs were significantly younger than those without recurrence (p = 0.002). In the meta-analysis, which included 1134 patients across 24 studies, the rate of recurrence was 4.8% (95% CI 3.0%-6.7%). The rate of AVM recurrence following radiosurgery was 0.7% (95% CI 0%-1.6%), which was significantly lower than the 8.5% rate (95% CI 5.0%-12.0%) following microsurgery. CONCLUSIONS Recurrence of obliterated brain AVMs is common in children. Recurrence is more common in young children and following microsurgery.
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Affiliation(s)
| | | | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and
| | - Gregory J Zipfel
- 2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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10
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2021; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Rhodes RH. Congenital Spinal Lipomatous Malformations. Part 2. Differentiation from Selected Closed Spinal Malformations. Fetal Pediatr Pathol 2021; 40:32-68. [PMID: 31535937 DOI: 10.1080/15513815.2019.1651799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital spinal lipomatous malformations (spinal lipomas, lipomyeloceles, and lipomyelomeningoceles) are closed neural tube defects over the lower back. Differentiation from some other closed neural tube defects in this region can be problematic for pathologists. MATERIALS AND METHODS This review is based on PubMed searches of the embryology, gross and histopathologic findings, and laboratory reporting requisites for retained medullary spinal cords, coccygeal medullary vestiges and cysts, myelocystoceles, true human vestigial tails, and pseudotails for comparison with congenital spinal lipomatous malformations. RESULTS Embryology, imaging, gross and histopathology of these closed neural tube lesions have different but overlapping features compared to congenital spinal lipomatous malformations, requiring context for diagnosis. CONCLUSION The lipomyelocele spectrum and to some degree all of the malformations discussed, even though they may not share gross appearance, anatomic site, surgical approach, or prognosis, require clinical and histopathologic correlation for final diagnosis.
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Affiliation(s)
- Roy H Rhodes
- Department of Pathology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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12
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Guerrero WR, Dandapat S, Ortega-Gutierrez S. Hemorrhagic Cerebrovascular Pathology in the Pediatric Population. Front Neurol 2020; 11:1055. [PMID: 33041990 PMCID: PMC7527474 DOI: 10.3389/fneur.2020.01055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hemorrhagic cerebrovascular disease in the pediatric population can have devastating and long-term effects. Progress in the fields of genetics, neuroimaging, pharmacology, and surgical techniques has led to improved diagnosis and management of pediatric cerebrovascular diseases. In this review we discuss the current etiologies and medical and surgical treatments of hemorrhagic cerebrovascular pathology affecting infants and children. A special emphasis is placed on neuroendovascular treatment options. Increased knowledge about this unique pathology and the medical and therapeutic options will empower practitioners to more quickly and accurately identify and accurately treat hemorrhagic diseases in the pediatric population.
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Affiliation(s)
- Waldo R Guerrero
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Sudeepta Dandapat
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
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13
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Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2020; 215:472-487. [DOI: 10.2214/ajr.19.22443] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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LoPresti MA, Goethe EA, Lam S. Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy. Childs Nerv Syst 2020; 36:1445-1452. [PMID: 31932976 DOI: 10.1007/s00381-020-04501-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children. METHODS A retrospective chart review was conducted examining patients age 0-18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage. RESULTS Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures. CONCLUSIONS Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
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Affiliation(s)
- Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sandi Lam
- Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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15
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Rhodes RH. Congenital Spinal Lipomatous Malformations. Part 1. Spinal Lipomas, Lipomyeloceles, and Lipomyelomeningoceles. Fetal Pediatr Pathol 2020; 39:194-245. [PMID: 31342816 DOI: 10.1080/15513815.2019.1641859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Lumbosacral spinal lipomas and lipomyeloceles are usually identified in early childhood. Terminology, histopathology, and diagnosis for these malformations can be confusing. Materials and Methods: This is a PubMed review with comparison of embryology, gross, and histopathology, and reporting requisites for these and related closed spinal malformations. Results: The spinal lipoma group (congenital spinal lipomatous malformations) includes subcutaneous, transdural, intradural, and noncontiguous malformations stretching through the entire lower spinal region. This lipomyelocele trajectory overlaps the embryonic tail's caudal eminence. Histopathologically, the lipomyelocele spectrum is a heterogeneous, stereotypical set of findings encountered from dermis to spinal cord. Diagnosis requires detailed correlation of images, intraoperative inspection, and histopathology. Conclusions: Appropriate terminology and clinicopathologic correlation to arrive at a diagnosis is a critical activity shared by pathologist and clinician. Prognostic and management differences depend on specific diagnoses. Familial and genetic influences play little if any role in patient management in closed spinal malformations.
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Affiliation(s)
- Roy H Rhodes
- LSUHSC, Pathology, New Orleans, Louisiana, USA.,Rutgers Robert Wood Johnson Medical School, Pathology, New Brunswick, New Jersey, USA
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16
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Eliava SS, Pilipenko YV, Yakovlev SB, Golanov AV, Maryashev SA, Grebenev FV. [Arteriovenous malformations of the brain in children: treatment results for 376 patients]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:22-34. [PMID: 32412191 DOI: 10.17116/neiro20208402122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
undefined Cerebral arteriovenous malformations (AVM) are increasingly detected in children. Objective To estimate the risk of hemorrhage in children with AVM before and after treatment and evaluate the outcomes of various methods of AVM management in children. Material and methods This study included 376 patients with various cerebral AVM under the age of 18 years. There were 273 patients with intracranial hemorrhage (72.6%). Results Recurrent hemorrhages within the first month were registered in 1.1% of patients with angiomatous AVM prior to treatment and in 15.4% of patients with fistulous AVM. Microsurgical resection of AVM was performed in 135 (35.9%) patients. Total resection was achieved in 97.8% of cases. There were no mortality after microsurgical procedures. Endovascular treatment was applied in 79 (21%) patients. Total embolization was achieved in 29.1% of patients. One patient (1.3%) died after endovascular procedure. Radiosurgery was performed in 140 (37.2%) patients with total obliteration after a single fraction in 64.4% of patients. Favorable long-term outcomes (GOS grades V-IV) were achieved in 89.6% of patients with available follow-up data (n=182). Recurrent hemorrhages were registered in 6% of patients (3.3% after radiosurgery, 2.7% after endovascular treatment). One patient with recurrent hemorrhage died after radiosurgery. Conclusion Early relapses of hemorrhage are not characteristic for children with cerebral AVM. Therefore, there are no indications for urgent surgery except for cases of intracerebral hematoma. In children, microsurgical treatment is preferred for angiomatous AVM, endovascular treatment - for fistulous AVM. Radiosurgery also ensures favorable outcomes. However, it is unreasonable to postpone AVM radiosurgical treatment in children with increased risk of recurrent hemorrhage considering relatively long period of post-radiation obliteration of AVM.
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Affiliation(s)
| | | | | | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - F V Grebenev
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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17
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Winkler EA, Lu A, Morshed RA, Yue JK, Rutledge WC, Burkhardt JK, Patel AB, Ammanuel SG, Braunstein S, Fox CK, Fullerton HJ, Kim H, Cooke D, Hetts SW, Lawton MT, Abla AA, Gupta N. Bringing high-grade arteriovenous malformations under control: clinical outcomes following multimodality treatment in children. J Neurosurg Pediatr 2020; 26:82-91. [PMID: 32276243 DOI: 10.3171/2020.1.peds19487] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs. METHODS A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram. RESULTS The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year). CONCLUSIONS Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs.
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Affiliation(s)
| | - Alex Lu
- Departments of1Neurological Surgery
| | | | | | | | - Jan-Karl Burkhardt
- Departments of1Neurological Surgery.,2Department of Neurosurgery, Baylor Medical Center, Houston, Texas; and
| | | | | | | | - Christine K Fox
- 4Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology; and
| | - Heather J Fullerton
- 4Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology; and
| | - Helen Kim
- 5Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | | | | | - Michael T Lawton
- Departments of1Neurological Surgery.,7Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Nalin Gupta
- Departments of1Neurological Surgery.,8Pediatrics
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Börcek AÖ, Çeltikçi E, Aksoğan Y, Rousseau MJ. Clinical Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations in Pediatric Patients: Systematic Review and Meta-Analysis. Neurosurgery 2020; 85:E629-E640. [PMID: 31131849 DOI: 10.1093/neuros/nyz146] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in pediatric patients exhibit remarkable differences in terms of management and outcomes. Owing to a paucity of relevant data pertaining to AVMs in pediatric patients, special interest and investigation are required for an improved understanding of the available evidence by clinicians. OBJECTIVE To determine the clinical outcomes of single-session stereotactic radiosurgery (SRS) for AVMs in pediatric patients. METHODS A systematic literature review was performed to identify studies that reported the outcomes of SRS for AVMs in pediatric patients. Data pertaining to variables such as obliteration rate, post-SRS new hemorrhage rate, post-SRS new neurological deficit rate, and mortality rate were extracted and analyzed using meta-analysis techniques. RESULTS Based on pooled data from 20 studies with 1212 patients, single-session SRS resulted in complete obliteration in 65.9% (95% confidence interval [CI], 60.5%-71.1%; I2 = 66.5%) patients. Overall complication rate (including new hemorrhage, new neurodeficit, and mortality) was 8.0% (95% CI, 5.1%-11.5%; I2 = 66.4%). Post-SRS new neurological deficit rate was 3.1% (95% CI, 1.3%-5.4%; I2 = 59.7%), and post-SRS hemorrhage rate was 4.2% (95% CI, 2.5%-6.3%; I2 = 42.7%). There was no significant difference between studies disaggregated by treatment method (Gamma Knife [Elekta AB] vs other), treatment year (before year 2000 vs after year 2000), median AVM volume reported (≥3 vs <3 cm3), median dose reported (≥20 vs <20 Gy), or follow-up period (≥36 vs <36 mo). CONCLUSION Single-SRS is a safe treatment alternative that achieves high obliteration rates and acceptable complication rates for AVMs in pediatric patients.
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Affiliation(s)
- Alp Özgün Börcek
- Division of Pediatric Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Emrah Çeltikçi
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Yiğit Aksoğan
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
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19
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Unnithan AKA. Overview of the current concepts in the management of arteriovenous malformations of the brain. Postgrad Med J 2020; 96:212-220. [DOI: 10.1136/postgradmedj-2019-137202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/12/2019] [Accepted: 01/11/2020] [Indexed: 12/12/2022]
Abstract
BackgroundThere is a lack of consensus in the management of arteriovenous malformations (AVMs) of the brain since ARUBA (A Randomised trial of Unruptured Brain Arteriovenous malformations) trial showed that medical management is superior to interventional therapy in patients with unruptured brain AVMs. The treatment of brain AVM is associated with significant morbidity.Objectives and methodsA review was done to determine the behaviour of brain AVMs and analyse the risks and benefits of the available treatment options. A search was done in the literature for studies on brain AVMs. Descriptive analysis was also done.ResultsThe angiogenic factors such as vascular endothelial growth factor and inflammatory cytokines are involved in the growth of AVMs. Proteinases such as matrix metalloproteinase-9 contribute to the weakening and rupture of the nidus. The risk factors for haemorrhage are prior haemorrhage, deep and infratentorial AVM location, exclusive deep venous drainage and associated aneurysms. The advancements in operating microscope and surgical techniques have facilitated microsurgery. Stereotactic radiosurgery causes progressive vessel obliteration over 2–3 years. Endovascular embolisation can be done prior to microsurgery or radiosurgery and for palliation.ConclusionsSpetzler-Martin grades I and II have low surgical risks. The AVMs located in the cerebellum, subarachnoid cisterns and pial surfaces of the brainstem can be treated surgically. Radiosurgery is preferable for deep-seated AVMs. A combination of microsurgery, embolisation and radiosurgery is recommended for deep-seated and Spetzler-Martin grade III AVMs. Observation is recommended for grades IV and V.
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LoPresti MA, Ravindra VM, Pyarali M, Goethe E, Gadgil N, Wagner K, Kan P, Lam S. Pediatric intracranial arteriovenous malformations: a single-center experience. J Neurosurg Pediatr 2020. [DOI: 10.3171/2019.9.peds19235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIntracranial arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. Exploring outcomes of treatment and factors that predict recurrence may help guide the management of pediatric AVMs. In this study, the authors review a single-center experience with pediatric AVMs, aiming to identify factors contributing to recurrence and areas for improvement in treatment.METHODSA single-center retrospective review of patients ages 0–18 years with AVMs in the period from 2005 to 2018 was conducted. Demographic, clinical, and radiographic data were collected and examined to compare the clinical and functional outcomes of patients managed with and those managed without open microsurgical resection.RESULTSOne hundred five patients were diagnosed and treated during the study period. Fifty (47.6%) had been treated surgically and 35 (33.3%) nonsurgically, and 20 (19%) had been treated primarily at an outside institution and thus were excluded from further analysis. Of the 50 treated surgically, 92% had complete obliteration on postoperative imaging, with the remaining patients having residual AVM and undergoing re-resection or SRS, ultimately resulting in a 96% radiographic cure rate. The surgically treated patients were followed up for an average of 3.34 years. Eighty-two percent had a modified Rankin Scale (mRS) score of 0–2. There was a recurrence rate of 12%, with the time to recurrence averaging 327.86 days (range 85–596 days). Of the 35 patients managed without open surgery, 77% underwent serial imaging surveillance, 20% underwent endovascular embolization, and 3% underwent stereotactic radiosurgery. Radiographic cure was seen in 6% of those treated nonsurgically, and all had undergone endovascular treatment alone. The nonsurgically treated patients were followed up for an average of 2.14 years. Eighty percent had an mRS score of 0–2.CONCLUSIONSThe data revealed that patients with lower-grade AVMs treated surgically and those with higher-grade AVMs managed without surgery have good functional and clinical outcomes. A high rate of recurrence was noted, and the possible contributing factors were explored. The authors encourage further study into mechanisms to reduce AVM recurrence in pediatric patients and look forward to advances in the medical management of lesions that are considered unresectable.
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Affiliation(s)
- Melissa A. LoPresti
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Vijay M. Ravindra
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Monika Pyarali
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Eric Goethe
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nisha Gadgil
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Kathyrn Wagner
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Subat YW, Dasenbrock HH, Gross BA, Patel NJ, Frerichs KU, Du R, Aziz-Sultan MA. Periprocedural intracranial hemorrhage after embolization of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg 2019; 133:1417-1427. [PMID: 31518979 DOI: 10.3171/2019.5.jns183204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary goal of the treatment of cerebral arteriovenous malformations (AVMs) is angiographic occlusion to eliminate future hemorrhage risk. Although multimodal treatment is increasingly used for AVMs, periprocedural hemorrhage after transarterial embolization is a potential endovascular complication that is only partially understood and merits quantification. METHODS Searching the period between 1990 and 2019, the authors of this meta-analysis queried the PubMed and Embase databases for studies reporting periprocedural hemorrhage (within 30 days) after liquid embolization (using cyanoacrylate or ethylene vinyl alcohol copolymer) of AVMs. Random effects meta-analysis was used to evaluate the pooled rate of flow-related hemorrhage (those attributed to alterations in AVM dynamics), technical hemorrhage (those related to procedural complications), and total hemorrhage. Meta-regression was used to analyze the study-level predictors of hemorrhage, including patient age, Spetzler-Martin grade, hemorrhagic presentation, embolysate used, intent of treatment (adjuvant vs curative), associated aneurysms, endovascular angiographic obliteration, year of study publication, and years the procedures were performed. RESULTS A total of 98 studies with 8009 patients were included in this analysis, and the mean number of embolization sessions per patient was 1.9. The pooled flow-related and total periprocedural hemorrhage rates were 2.0% (95% CI 1.5%-2.4%) and 2.6% (95% CI 2.1%-3.0%) per procedure and 3.4% (95% CI 2.6%-4.2%) and 4.8% (95% CI 4.0%-5.6%) per patient, respectively. The mortality and morbidity rates associated with hemorrhage were 14.6% and 45.1%, respectively. Subgroup analyses revealed a pooled total hemorrhage rate per procedure of 1.8% (95% CI 1.0%-2.5%) for adjuvant (surgery or radiosurgery) and 4.6% (95% CI 2.8%-6.4%) for curative intent. The treatment of aneurysms (p = 0.04) and larger patient populations (p < 0.001) were significant predictors of a lower hemorrhage rate, whereas curative intent (p = 0.04), angiographic obliteration achieved endovascularly (p = 0.003), and a greater number of embolization sessions (p = 0.03) were significant predictors of a higher hemorrhage rate. There were no significant differences in periprocedural hemorrhage rates according to the years evaluated or the embolysate utilized. CONCLUSIONS In this study-level meta-analysis, periprocedural hemorrhage was seen after 2.6% of transarterial embolization procedures for cerebral AVMs. The adjuvant use of endovascular embolization, including in the treatment of associated aneurysms and in the presurgical or preradiosurgical setting, was a study-level predictor of significantly lower hemorrhage rates, whereas more aggressive embolization involving curative intent and endovascular angiographic obliteration was a predictor of a significantly higher total hemorrhage rate.
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Affiliation(s)
- Yosuf W Subat
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 4Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Hormuzdiyar H Dasenbrock
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 3Department of Neurosurgery, Rush University, Chicago, Illinois
| | - Bradley A Gross
- 5Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Nirav J Patel
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Kai U Frerichs
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - M Ali Aziz-Sultan
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
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22
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Al-Smadi AS, Ansari SA, Shokuhfar T, Malani A, Sattar S, Hurley MC, Potts MB, Jahromi BS, Alden TD, Dipatri AJ, Shaibani A. Safety and outcome of combined endovascular and surgical management of low grade cerebral arteriovenous malformations in children compared to surgery alone. Eur J Radiol 2019; 116:8-13. [PMID: 31153578 DOI: 10.1016/j.ejrad.2019.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the outcomes of combined preoperative embolization and microsurgical resection in comparison with microsurgical resection alone as the current standard of care for low-grade cerebral arteriovenous malformations (AVM) in the pediatric population. MATERIALS & METHODS We performed a single-center retrospective study of pediatric patients presenting with Spetzler-Martin (SM) grade I and II cerebral AVMs at a high-volume tertiary pediatric hospital between January 2005 and September 2016. Low grade AVM patients were divided into two groups: pre-operative embolization with subsequent microsurgical resection or microsurgical resection alone. Patient demographics, clinical and imaging presentations, AVM morphological characteristics, post-operative complications, and mid to long-term clinical outcomes were studied. Post-embolization and post-surgical outcomes were assessed prior to and after treatment, at 3 months and at final follow-up using the modified Rankin Scale (mRS) to compare both final independent (mRS 0-2) and favorable (no change or improved mRS) clinical outcomes for comparison between study groups. Statistical associations of patient demographics, AVM characteristics/SM grading, and treatment modality group with post-operative complications were performed using univariate logistic regression analysis. RESULTS Thirty-four patients with low grade cerebral AVMs met the study inclusion criteria (mean age 10.6 ± 3.4 years; range 3-16 years, 22M:12 F). Twenty patients (59%) presented with ruptured AVMs. Twenty-five patients (73.5%) underwent combined treatment with embolization and microsurgical resection, while 9/34 (26.5%) underwent microsurgical resection alone. A total of 35 embolization procedures performed in 25 patients (Mode, 1; Range, 1-7) were associated with two minor post-embolization and 7 subsequent post-surgical (28%) complications, resulting in clinical deterioration in a single patient. Microsurgical resection alone was associated with 3 post-surgical complications (33%), resulting in permanent neurological disability in a single patient. There was no significance association of post-operative complications with either treatment modality group, combined treatment versus surgical resection alone [OR:1.13; 95% CI:0.23-5.62; p-value 0.88]. SM Grade II and eloquent locations were found to be significantly associated with post-surgical complications of low grade pediatric cerebral AVMs [OR 13.2 and OR 8 respectively, p-value 0.004 and 0.005). On mean follow-up time of 35.7 months, final clinical outcome was favorable in the majority of both treatment arms with no dependent (mRS>2) patients in the combined endovascular and surgical cohort. Two patients in the surgical cohort failed to achieve independent functional status, primarily due to a pre-operative morbid status (p-value 0.015). However, there was no significant difference in favorable outcomes between the treatment groups [p-value 0.14]. CONCLUSION Our study suggests equivalent safety and favorable clinical outcomes related to combined endovascular embolization and microsurgical resection of low grade pediatric cerebral AVMs in comparison to microsurgical resection alone. On long term clinical follow-up, the vast majority of patients achieved an independent and favorable functional status irrespective of pre-operative embolization.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Sameer A Ansari
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tahaamin Shokuhfar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Aresha Malani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Saadia Sattar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Michael C Hurley
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Matthew B Potts
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Babak S Jahromi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tord D Alden
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Arthur J Dipatri
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Ali Shaibani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States.
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23
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Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation. Neurochirurgie 2018; 64:316-320. [PMID: 29908698 DOI: 10.1016/j.neuchi.2018.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/20/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.
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24
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Richardson S, Khandeparker RV, Raghuvaram AK, Mohan R. Modified two flap palatoplasty in asymptomatic transsphenoidal encephalocele: a case report. J Korean Assoc Oral Maxillofac Surg 2018; 44:86-90. [PMID: 29732314 PMCID: PMC5932277 DOI: 10.5125/jkaoms.2018.44.2.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/03/2016] [Accepted: 08/17/2016] [Indexed: 11/21/2022] Open
Abstract
About one-third of patients with transsphenoidal basal encephaloceles have associated congenital anomalies, including cleft palate. Moreover, they are often plagued by symptomatic exacerbations in the form of upper respiratory obstructions, cerebrospinal fluid leaks, meningitis, etc., with few patients being asymptomatic. We herein present a rare asymptomatic case of transsphenoidal basal encephalocele in an 18-month-old child with cleft palate and highlight a modified version of two-flap palatoplasty.
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Affiliation(s)
| | | | | | - Ram Mohan
- Oral and Maxillofacial Surgery, Private Practitioner, Krishnagiri, India
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25
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Duranovic V, Vulin K, Dakovic I, Lenicek Krleza J, Delin S, Galinovic I, Marjanovic J, Tripalo Batos A, Plesa Premilovac Z, Mejaski Bosnjak V. The characteristics of transcranial color-coded duplex sonography in children with cerebral arteriovenous malformation presenting with headache. Childs Nerv Syst 2018; 34:199-203. [PMID: 29249075 DOI: 10.1007/s00381-017-3692-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/06/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE Cerebral arteriovenous malformations (AVM) are uncommon lesions. They are most often presented in childhood as intracranial hemorrhage. The aim of this report is to present the use of transcranial color-coded duplex sonography (TCCS) in detection of AVMs in children suffering headache. METHODS This report describes five pediatric patients with headache and cerebral AVM which were initially discovered by TCCS. Diagnosis was confirmed by magnetic resonance imaging and digital subtraction angiography. RESULTS In all patients, TCCS showed saccular enlargement of the vessels with a multicolored pattern corresponding to the different directions of blood flow. Spectral analysis showed significantly high flow systolic and diastolic velocities and low resistance index. CONCLUSIONS In this report, we describe TCCS as a valuable non-invasive, harmless, low-cost, widely available method for the detection and follow-up of hemodynamic changes of AVMs in children with headache, before and after treatment.
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Affiliation(s)
- Vlasta Duranovic
- Department of Neuropediatrics, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia.
| | - Katarina Vulin
- Department of Pediatrics, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - Ivana Dakovic
- Department of Pediatrics, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | - Jasna Lenicek Krleza
- Specialist of Laboratory Medicine, Children's Hospital Zagreb, Department of Biochemistry and Hematology, Institute of Laboratory diagnostics, Klaiceva 16, 10000, Zagreb, Croatia
| | - Sanja Delin
- Department of Pediatrics, General Hospital Zadar, Boze Pericica 5, 23000, Zadar, Croatia
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Josip Marjanovic
- Radiology Department, Royal Belfast Hospital for Sick Children, 274 Grosvenor Road, Belfast, BT12 6BA, UK
| | - Ana Tripalo Batos
- Department of Pediatric Radiology, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
| | | | - Vlatka Mejaski Bosnjak
- Department of Neuropediatrics, Children's Hospital Zagreb, Klaiceva 16, 10000, Zagreb, Croatia
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26
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Srinivasan VM, Gressot LV, Daniels BS, Jones JY, Jea A, Lam S. Management of intracerebral hemorrhage in pediatric neurosurgery. Surg Neurol Int 2017; 7:S1121-S1126. [PMID: 28194298 PMCID: PMC5299152 DOI: 10.4103/2152-7806.196919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 12/03/2022] Open
Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Loyola V Gressot
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Bradley S Daniels
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Jeremy Y Jones
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Andrew Jea
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
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27
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Jimenez JE, Gersey ZC, Wagner J, Snelling B, Ambekar S, Peterson EC. Role of follow-up imaging after resection of brain arteriovenous malformations in pediatric patients: a systematic review of the literature. J Neurosurg Pediatr 2017; 19:149-156. [PMID: 27911246 DOI: 10.3171/2016.9.peds16235] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pediatric patients are at risk for the recurrence of brain arteriovenous malformation (AVM) after resection. While there is general consensus on the importance of follow-up after surgical removal of an AVM, there is a lack of consistency in the duration of that follow-up. The object of this systematic review was to examine the role of follow-up imaging in detecting AVM recurrence early and preventing AVM rupture. METHODS This systematic review was performed using articles obtained through a search of the literature contained in the MeSH database, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Search results revealed 1052 articles, 13 of which described 31 cases of AVM recurrence meeting the criteria for inclusion in this study. Detection of AVM occurred significantly earlier (mean ± SD, 3.56 ± 3.67 years) in patients with follow-up imaging than in those without (mean 8.86 ± 5.61 years; p = 0.0169). While 13.34% of patients who underwent follow-up imaging presented with rupture of a recurrent AVM, 57.14% of those without follow-up imaging presented with a ruptured recurrence (p = 0.0377). CONCLUSIONS Follow-up imaging has an integral role after AVM resection and is sometimes not performed for a sufficient period, leading to delayed detection of recurrence and an increased likelihood of a ruptured recurrent AVM.
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Affiliation(s)
- Joaquin E Jimenez
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Zachary C Gersey
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jason Wagner
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brian Snelling
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Sudheer Ambekar
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eric C Peterson
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
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28
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El-Ghanem M, Kass-Hout T, Kass-Hout O, Alderazi YJ, Amuluru K, Al-Mufti F, Prestigiacomo CJ, Gandhi CD. Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature. INTERVENTIONAL NEUROLOGY 2016; 5:218-225. [PMID: 27781052 DOI: 10.1159/000447605] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy.
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Affiliation(s)
- Mohammad El-Ghanem
- Department of Neurology, Pennsylvania State University, Hershey, Pa, N.Y., USA
| | - Tareq Kass-Hout
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA; Division of Neuro-Endovascular Surgery, Department of Surgery, Rochester Regional Health System, Rochester, N.Y., USA
| | - Omar Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, Va, N.Y., USA
| | - Yazan J Alderazi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Krishna Amuluru
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Chirag D Gandhi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
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29
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Nerva JD, Kim LJ, Barber J, Rockhill JK, Hallam DK, Ghodke BV, Sekhar LN. Outcomes of Multimodality Therapy in Pediatric Patients With Ruptured and Unruptured Brain Arteriovenous Malformations. Neurosurgery 2015; 78:695-707. [DOI: 10.1227/neu.0000000000001076] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Brain arteriovenous malformations (BAVMs) are a frequent cause of pediatric hemorrhagic stroke, which frequently results in significant morbidity and mortality.
OBJECTIVE:
To analyze the results of multimodality treatment for a consecutive series of pediatric patients with ruptured and unruptured BAVMs at a single institution.
METHODS:
Forty patients <18 years of age were retrospectively reviewed. Results were divided by hemorrhage status, ie, ruptured or unruptured, and the intended curative treatment modality, ie, surgical resection or stereotactic radiosurgery.
RESULTS:
Twenty-seven patients (68%) presented with hemorrhage, and 13 patients (32%) presented without hemorrhage. Among ruptured patients, 19 (70%) underwent surgery and 8 (30%) underwent stereotactic radiosurgery. In surviving patients who presented with hemorrhage, 23 of 26 (88%) had a modified Rankin Scale (mRS) score of 0 to 2 at the last follow-up, and 24 of 26 (92%) obtained radiographic cure. For unruptured BAVMs, all 6 patients with grade I to III BAVM obtained radiographic cure and had an mRS score of 0 to 1 at the last follow-up, whereas 1 of 5 patients (20%) with grade IV and V BAVM had BAVM obliteration and a mean mRS score of 1.8 at the last follow-up. In a total of 93.6 years of follow-up from date of presentation to last clinical follow-up, there was 1 hemorrhage (1.1%/y). Of 30 patients with radiographic obliteration, 2 patients had radiographic recurrence (7% incidence).
CONCLUSION:
The majority of ruptured patients had an mRS score of 0 to 2 at the last follow-up and obtained radiographic cure. Unruptured patients with grade I to III BAVMs had superior outcomes compared with those with grade IV and V AVMs. Treatment of grade I to III BAVMs appears safe, and additional study is needed to determine optimal strategies for the management of unruptured grade IV and V BAVMs.
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Affiliation(s)
- John D. Nerva
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Louis J. Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Radiology, and University of Washington, Seattle, Washington
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason K. Rockhill
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Radiation Oncology, University of Washington, Seattle, Washington
| | - Danial K. Hallam
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Radiology, and University of Washington, Seattle, Washington
| | - Basavaraj V. Ghodke
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Radiology, and University of Washington, Seattle, Washington
| | - Laligam N. Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
- Department of Radiology, and University of Washington, Seattle, Washington
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30
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Mendes GA, Iosif C, Silveira EP, Waihrich E, Saleme S, Mounayer C. Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations. Neurosurgery 2015; 78:458-65. [DOI: 10.1227/neu.0000000000001057] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Transvenous embolization is a developing concept for curative therapy of cerebral arteriovenous malformations (AVMs). The feasibility of this endovascular method has not been reported in children.
OBJECTIVE:
To report our experience treating pediatric AVMs with the transvenous approach (TVA).
METHODS:
A cohort of 7 pediatric patients (younger than 18 years of age) who underwent the TVA for cerebral AVMs between January 2012 and January 2014. The TVA was used alone or in conjunction with other arterial approaches in definitive embolization sessions. Patient demographics, AVM characteristics, clinical outcomes, and angiographic results were independently assessed. Pial arteriovenous fistulae and vein of Galen malformations were excluded. Control angiograms were obtained at 6 months, and curative treatment was determined by the anatomic obliteration of the nidus.
RESULTS:
All patients had anatomic exclusion of the AVM. The mean size was 2 ± 0.6 cm, and hemorrhage was the most common presentation (100%, n = 7). Most AVMs were deeply placed (71%, n = 5), and a proximal approach to the nidus was achieved in all cases. Transvenous embolization alone was performed in 3 patients (43%), whereas combined arterial and venous embolization was required in 4 patients (57%). The mean follow-up period was 20.2 ± 10.5 months. There were no hemorrhagic or thromboembolic events, and venous infarction was not documented. No recurrence was documented.
CONCLUSION:
This is the first report that demonstrates the feasibility of transvenous Onyx embolization of AVMs in the pediatric population. Such a technique may be considered in certain AVMs that meet anatomic criteria in which microsurgery and radiosurgery might not be indicated.
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Affiliation(s)
- George A.C. Mendes
- Department of Interventional Neuroradiology, Dupuytren University Hospital, Limoges, France
| | - Christina Iosif
- Department of Interventional Neuroradiology, Dupuytren University Hospital, Limoges, France
| | | | - Eduardo Waihrich
- Department of Interventional Neuroradiology, Dupuytren University Hospital, Limoges, France
| | - Suzana Saleme
- Department of Interventional Neuroradiology, Dupuytren University Hospital, Limoges, France
| | - Charbel Mounayer
- Department of Interventional Neuroradiology, Dupuytren University Hospital, Limoges, France
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31
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Unique double recurrence of cerebral arteriovenous malformation. Acta Neurochir (Wien) 2015; 157:1461-6. [PMID: 26153777 DOI: 10.1007/s00701-015-2461-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
Surgically treated patients with arteriovenous malformations (AVMs) are considered cured when the postoperative angiogram proves complete resection. However, despite no residual nidus or early draining vein on postoperative angiogram, rare instances of AVM recurrence have been reported in adults. In this paper, the authors present a case of a 24-year-old woman with asymptomatic double recurrence of her cerebral AVM after angiographically proven complete resection. To the authors' knowledge, this patient represents the first case with double de novo asymptomatic recurrence of Spetzler-Martin grade I AVM. Also, she represents the first case with unique AVM criteria in each recurrence.
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32
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Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience. J Neurosurg Pediatr 2015; 15:71-7. [PMID: 25360855 DOI: 10.3171/2014.9.peds146] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0-2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Rangaswamy N, Pramanik AK. A novel technique in airway management of neonates with occipital encephalocele. J Perinatol 2014; 34:877-8. [PMID: 25359415 DOI: 10.1038/jp.2014.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/14/2014] [Indexed: 11/09/2022]
Abstract
Airway stabilization in neonates with occipital encephalocele (OE) is critical during surgery or if they develop hypoxic-respiratory failure. Endotracheal intubation can be challenging due to difficulty in positioning the head in a patient with large occipital mass. We describe a novel technique for positioning neonates with large OE using a commonly used hospital apparatus which facilitated appropriate positioning of the baby and successful endotracheal intubation with ease and no additional staff.
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Affiliation(s)
- N Rangaswamy
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, LSU Health, Shreveport, LA, USA
| | - A K Pramanik
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, LSU Health, Shreveport, LA, USA
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Potts MB, Sheth SA, Louie J, Smyth MD, Sneed PK, McDermott MW, Lawton MT, Young WL, Hetts SW, Fullerton HJ, Gupta N. Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes. J Neurosurg Pediatr 2014; 14:1-11. [PMID: 24766309 DOI: 10.3171/2014.3.peds13381] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
UNLABELLED OBJECT.: Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. METHODS The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. RESULTS A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm(3) (range 0.09-62.3 cm(3)), and median prescription marginal dose used was 17.5 Gy (range 12-20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18-20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%-37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0-2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. CONCLUSIONS A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.
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Secci F, Consales A, Merciadri P, Ravegnani GM, Piatelli G, Pavanello M, Cama A. Naso-ethmoidal encephalocele with bilateral orbital extension: report of a case in a western country. Childs Nerv Syst 2013; 29:1947-52. [PMID: 23780401 DOI: 10.1007/s00381-013-2125-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Encephalocele is a rare congenital malformation of the central nervous system with protrusion of cranial content (meninges, brain, and ventricles in different combinations) beyond the normal confines of the skull. Anterior encephaloceles occur with a high frequency in Southeast Asia, while in the Western countries occipital encephaloceles prevail. The treatment of an anterior (naso-ethmoidal) encephalocele involves a neurosurgeon or a multidisciplinary team (neurosurgeon, maxillofacial surgeon, plastic surgeon, and ENT surgeon) dealing with craniofacial surgery. Goals of surgery include removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal and cutaneous structures. The prognosis depends from the anatomical site, volume of neural contents, and the presence of coexisting malformations. CASE REPORT We report the case of an Italian child suffering from a naso-ethmoidal encephalocele with bilateral orbital extension. The surgical treatment was performed in two steps. CONCLUSION Sincipital encephalocele is a complex pathology without a unique standardized surgical treatment. Its low incidence in Western countries can make its management particularly tricky.
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Affiliation(s)
- Francesca Secci
- Department of Neurosurgery, Giannina Gaslini Children's Research Hospital (IRCSS), Largo Gerolamo Gaslini 5, Genoa, Italy
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Frisoli FA, Lang SS, Vossough A, Cahill AM, Heuer GG, Dahmoush HM, Storm PB, Beslow LA. Intrarater and interrater reliability of the pediatric arteriovenous malformation compactness score in children. J Neurosurg Pediatr 2013; 11:547-51. [PMID: 23495808 PMCID: PMC3644017 DOI: 10.3171/2013.2.peds12465] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral arteriovenous malformations (AVMs) have a higher postresection recurrence rate in children than in adults. The authors' previous study demonstrated that a diffuse AVM (low compactness score) predicts postresection recurrence. The aims of this study were to evaluate the intra- and interrater reliability of the AVM compactness score. METHODS Angiograms of 24 patients assigned a preoperative compactness score (scale of 1-3; 1 = most diffuse, 3 = most compact) in the authors' previous study were rerated by the same pediatric neuroradiologist 9 months later. A pediatric neurosurgeon, pediatric neuroradiology fellow, and interventional radiologist blinded to each other's ratings, the original ratings, and AVM recurrence also rated each AVM's compactness. Intrarater and interrater reliability were calculated using the κ statistic. RESULTS Of the 24 AVMs, scores by the original neuroradiologist were 1 in 6 patients, 2 in 16 patients, and 3 in 2 patients. Intrarater reliability was 1.0. The κ statistic among the 4 raters was 0.69 (95% CI 0.44-0.89), which indicates substantial reliability. The interrater reliability between the neuroradiologist and neuroradiology fellow was moderate (κ = 0.59 [95%CI 0.20-0.89]) and was substantial between the neuroradiologist and neurosurgeon (κ = 0.74 [95% CI 0.41-1.0]). The neuroradiologist and interventional radiologist had perfect agreement (κ = 1.0). CONCLUSIONS Intrarater and interrater reliability of the AVM compactness score were excellent and substantial, respectively. These results demonstrate that the AVM compactness score is reproducible. However, the neuroradiologist and interventional radiologist had perfect agreement, which indicates that the compactness score is applied most accurately by those with extensive angiography experience.
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Affiliation(s)
- Fabio A Frisoli
- Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA
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Nataraj A, Mohamed MB, Gholkar A, Vivar R, Watkins L, Aspoas R, Gregson B, Mitchell P, Mendelow AD. Multimodality treatment of cerebral arteriovenous malformations. World Neurosurg 2013; 82:149-59. [PMID: 23454686 DOI: 10.1016/j.wneu.2013.02.064] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 02/07/2013] [Accepted: 02/13/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Many arteriovenous malformations (AVMs) can be treated with one modality, but with increasing complexity a combination of techniques, including surgical excision, embolization, and radiosurgery, may be beneficial. The 2 senior authors' experience in the multimodal management of AVMs from 1980-2008 is reported, including the results in all patients with rehemorrhage while awaiting treatment or after partial initial treatment has begun. The series contains a disproportionately high number of Spetzler-Martin grade IV and V lesions, owing to the nature of the referral practice. METHODS Data were collected prospectively. Only patients who were managed until treatment options were exhausted were included; this entailed either treatment to the point of AVM obliteration or inability to treat further using any or all modalities. Patients who presented with intracranial hemorrhage (ICH) in extremis in whom the AVM was excised during the first operation were also included. RESULTS Of the 290 patients, 265 underwent treatment, and 25 were managed conservatively. An unruptured AVM was present in 48% of patients. Cure was achieved in 233 (88%) of treated patients. Cure was achieved in 25 of 37 patients undergoing radiosurgery only, 56 of 57 undergoing surgery, 100 of 101 undergoing embolization and microsurgical excision, 20 of 34 undergoing embolization alone, 12 of 17 undergoing embolization and radiosurgery, 5 of 5 undergoing surgery and radiosurgery, and 14 of 14 patients undergoing all 3 modalities. Spetzler-Martin grade was found to correlate negatively with cure (P < 0.001). There was a good outcome in 210 patients (72%), moderate disability in 40 patients (14%), severe disability in 22 patients (8%), vegetative state in 1 patient, and 17 patients (6%) died. There was a favorable outcome (no or only moderate deficits) in 93% of patients with Spetzler-Martin grade I-III lesions. The outcome was favorable in 13 of 25 patients (52%) having no treatment, 32 of 37 (86%) having radiosurgery only, 30 of 34 (88%) having embolization only, 54 of 57 (95%) having surgery only, 87 of 101 (86%) having embolization and surgery, 16 of 17 (94%) having embolization and radiosurgery, 5 of 5 (100%) having surgery and radiosurgery, and 13 of 14 (93%) having all 3 modalities. These outcomes included morbidity from initial presenting symptoms, from treatment, and from rehemorrhage. Good recovery was more likely in patients who were treated with surgery as one of the treatments (P = .025). Considering only new deficits related to treatment, 9 patients (3%) incurred severe neurologic deficits, 11 patents died after treatment, 2 patients died of postoperative hematomas, and 6 died of rehemorrhage from residual AVM. Increasing age, Spetzler-Martin grade, and rehemorrhage were correlated with a poorer Glasgow Outcome Scale score (P < 0.05). CONCLUSIONS These data suggest a higher risk of hemorrhage after partial obliteration of AVM. One should ascertain an acceptably high likelihood of complete obliteration before embarking on treatment. Using a multimodality approach, the authors were able to cure 92% of treated Spetzler-Martin grade I-IV lesions but only 53% of treated Spetzler-Martin grade V lesions. A major neurologic deficit, disabling to the patient, was incurred in 3% of cases, and 11 patients died.
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Affiliation(s)
- Andrew Nataraj
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom; Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - M Bahgaat Mohamed
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom; Department of Neurosurgery, Minya University Hospital, Minya, Egypt
| | - Anil Gholkar
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
| | - Ramon Vivar
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
| | - Laurence Watkins
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Robert Aspoas
- Department of Neurosurgery, Oldchurch Hospital, Romford, United Kingdom
| | - Barbara Gregson
- Department of Neurosciences, University of Newcastle, Newcastle-upon-Tyne, United Kingdom
| | - Patrick Mitchell
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
| | - A David Mendelow
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
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Ashour R, Aziz-Sultan MA, Soltanolkotabi M, Schoeneman SE, Alden TD, Hurley MC, Dipatri AJ, Tomita T, Elhammady MS, Shaibani A. Safety and Efficacy of Onyx Embolization for Pediatric Cranial and Spinal Vascular Lesions and Tumors. Neurosurgery 2012; 71:773-84. [DOI: 10.1227/neu.0b013e3182648db6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Although Onyx is widely used to embolize vascular lesions in adults, the safety and efficacy of this liquid embolic agent for use in children are not well studied.
OBJECTIVE:
To report our experience using Onyx in pediatric patients for a variety of cranial and spinal vascular lesions and tumors to determine its procedural complication rates, types, and clinical consequences and to highlight the indications for and principles of Onyx embolization in pediatric patients.
METHODS:
All pediatric Onyx embolization cases performed consecutively by the neuroendovascular services at our 2 institutions over a 5-year period were collected retrospectively and analyzed.
RESULTS:
Over the study period, 105 Onyx embolization procedures were performed in 69 pediatric patients with a mean follow-up of 112 days. Fifty-two patients harbored “primary” vascular lesions (malformations, fistulas, etc), whereas 17 patients had tumors. Complications occurred in 25 of 105 procedures (23.8%) and included ischemic infarct (7), asymptomatic nontarget embolization (4), intracerebral hemorrhage (3), microcatheter-related vessel perforation (3), retained microcatheter (2), cerebral edema (2), dimethyl sulfoxide-induced pulmonary edema (2), facial ischemia (1), and contrast-induced bronchospasm (1). Neurological morbidity occurred transiently after 10 procedures (9.5%) and permanently after 2 procedures (1.9%). There were no procedure-related deaths. Statistical analysis revealed no predictors of complications among the multiple potential risk factors evaluated.
CONCLUSION:
Our experience suggests that Onyx can be used effectively for embolization of pediatric cranial and spinal vascular lesions and tumors with low permanent morbidity; however, attention must be paid to the technical nuances of and indications for its use to avoid potential complications.
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Affiliation(s)
- Ramsey Ashour
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Mohammad Ali Aziz-Sultan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Maryam Soltanolkotabi
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samantha E. Schoeneman
- Department of Medical Imaging, Children's Memorial Hospital, Children's Memorial Hospital, Chicago, Illinois
| | - Tord D. Alden
- Division of Neurosurgery, Children's Memorial Hospital, Chicago, Illinois
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael C. Hurley
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Arthur J. Dipatri
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Neurosurgery, Children's Memorial Hospital, Chicago, Illinois
| | - Tadanori Tomita
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Neurosurgery, Children's Memorial Hospital, Chicago, Illinois
| | - Mohamed Samy Elhammady
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ali Shaibani
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Morgan MK, Patel NJ, Simons M, Ritson EA, Heller GZ. Influence of the combination of patient age and deep venous drainage on brain arteriovenous malformation recurrence after surgery. J Neurosurg 2012; 117:934-41. [PMID: 22957526 DOI: 10.3171/2012.8.jns12351] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Case reports suggest that young age is a critical factor in determining recurrence of brain arteriovenous malformations (AVMs) after surgery. However, other factors that may contribute to the increased risk of recurrence have not been considered. In this study, the authors' goal was to ascertain the risk and risk factors of recurrence after resection of AVMs of the brain. METHODS A consecutive case series (prospectively collected data) of 600 cases of resection of brain AVMs was retrospectively analyzed. Radiological evidence of recurrence or nonrecurrence, as well as clinical evidence of recurrence, could be established in 427 of these cases that underwent follow-up for more than 350 days after initial surgery. These cases were analyzed using Kaplan-Meier curves and Cox regression with respect to age and the presence of deep venous drainage. RESULTS Nine recurrent AVMs were found in 8 patients. By analysis of the Kaplan-Meier curves, the 10-year recurrence rate was 14% for those with deep venous drainage, compared with 4% for those without deep venous drainage. Stratifying by age, in the 0- to 20-year age group, the 10-year recurrence rates were 63% and 13% for those with and without deep venous drainage, respectively. In the 20- to 39-year age group, the rates were 5% and 0% respectively, and in the 40-year and older age group they were 0% and 3%, respectively. The hazard ratio for deep venous drainage, adjusted for age, was 5.97 (95% CI 1.20-29.69, p = 0.029). CONCLUSIONS The risk of recurrence after AVM resection is significant for young patients with deep venous drainage.
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Affiliation(s)
- Michael Kerin Morgan
- Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia.
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Eguchi S, Aihara Y, Yamaguchi K, Okada Y. Limitations of fetal ultrasonography and magnetic resonance imaging in prenatal diagnosis of congenital cerebral arteriovenous malformations with hemorrhagic onset. J Neurosurg Pediatr 2012; 10:154-8. [PMID: 22725727 DOI: 10.3171/2012.4.peds11517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A fetus at 30 gestational weeks was observed on fetal ultrasonography to have a dilated right lateral ventricle. After delivery, the entity was diagnosed as a prenatal intracerebral hemorrhage (ICH) due to a ruptured arteriovenous malformation (AVM). Ultrasonography and MRI examinations performed before birth indicated a cerebral aneurysm in the territory of the right middle cerebral artery. However, digital subtraction angiography revealed an intracystic hemorrhage due to a ruptured cerebral AVM. Arteriovenous malformations in children are rare, difficult to diagnose, and result in permanent sequelae after delayed treatment. Patient prognosis depends on early and accurate diagnosis and intervention. Outcomes can be improved if an AVM in a child is detected at the onset of ICH for young infants in the prenatal or early postnatal periods. Early AVM diagnosis is limited to fetal ultrasonography and MRI, and special consideration through invasive examination including neonatal digital subtraction angiography is urged unless a correct and clear diagnosis is made at an early stage. Prenatal ICH due to an AVM is rare. The authors discuss their observations and findings.
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Affiliation(s)
- Seiichiro Eguchi
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
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Cerebral arteriovenous malformations and seizures: differential impact on the time to seizure-free state according to the treatment modalities. Acta Neurochir (Wien) 2012; 154:1003-10. [PMID: 22492295 DOI: 10.1007/s00701-012-1339-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND To determine the prognostic factors for the incidence and the outcome of seizure in patients with cerebral arteriovenous malformation (AVM) and to identify the time to seizure-free state according to the treatment modalities. MATERIAL AND METHODS Between 1995 and 2008, the multidisciplinary team at our institution treated 399 patients with cerebral AVMs. Treatment consisted of surgical resection, radiosurgery, and embolization, either alone or in combination. The median follow-up period was 6.0 years (range, 3.0-16.2 years). Eighty-six patients (21.5 %) experienced seizures before treatment. We investigated the variables associated with seizure incidence and seizure outcome and analyzed the outcomes of seizure among each treatment modality. RESULTS After treatment, 60 (70 %) patients were seizure-free. Compared with 313 patients who did not experience seizures, we found that younger age (≤ 35 years), size ≥ 3 cm, and location of temporal lobe were associated with seizures (p < 0.05). Short seizure history, accompanying intracerebral hemorrhage, generalized tonic-clonic type seizure, deep-seated or infratentorial AVM, complete obliteration of AVM, and a favorable neurological outcome at 12 months were closely associated with Engel Class I outcomes (p < 0.05). Seizure-free outcomes after microsurgery, radiosurgery, or embolization were 78 %, 66 %, and 50 %, respectively. The overall annual bleeding rate was 1.0 % and 2.2 % in microsurgery-treated and radiosurgery-treated AVMs, respectively. In the surgery group, the median time to seizure-free status was 1.1 months (95 % CI, 0.7-1.2 months), whereas the radiosurgery group and embolization-alone group showed 20.5 months (95 % CI, 18.3-23.8 months), and 8.1 months (95 % CI, 6.0-13.5 months), respectively. CONCLUSIONS A multidisciplinary team approach for cerebral AVMs achieved satisfactory seizure control results. Microsurgery led to the highest percentage of seizure-free outcomes and had the lowest annual bleeding rate, whereas radiosurgery had a higher bleeding rate. Median time to seizure-free status in surgically treated patients was shorter than in patients who underwent radiosurgical or endovascular treatment.
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Lang SS, Beslow LA, Bailey RL, Vossough A, Ekstrom J, Heuer GG, Storm PB. Follow-up imaging to detect recurrence of surgically treated pediatric arteriovenous malformations. J Neurosurg Pediatr 2012; 9:497-504. [PMID: 22546027 PMCID: PMC3484378 DOI: 10.3171/2012.1.peds11453] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The true postoperative incidence of arteriovenous malformation (AVM) recurrence in the pediatric population remains largely unreported. Some literature suggests that delayed imaging studies should be obtained at 6 months to 1 year after negative findings on a postoperative angiogram. The aim of this study was to describe the timing of AVM recurrences after resection and the neuroimaging modalities on which the recurrences were detected. METHODS This study was performed in a retrospective cohort of all pediatric patients treated surgically for AVM resection by a single neurosurgeon between 2005 and 2010. Patients were followed after resection with MR angiography (MRA) or conventional angiography, when possible, at various time points. A visual scale for compactness of the initial AVM nidus was used, and the score was correlated with probability of recurrence after surgery. RESULTS A total of 28 patients (13 female, 15 male) underwent an AVM resection. In 18 patients (64.3%) an intraoperative angiogram was obtained. In 4 cases the intraoperative angiogram revealed residual AVM, and repeat resections were performed immediately. Recurrent AVMs were found in 4 children (14.3%) at 50, 51, 56, and 60 weeks after the initial resection. Recurrence risk was 0.08 per person-year. No patient with normal results on an angiogram obtained at 1 year developed a recurrence on either a 5-year angiogram or one obtained at 18 years of age. All patients with recurrence had a compactness score of 1 (diffuse AVM); a lower compactness score was associated with recurrence (p = 0.0003). CONCLUSIONS All recurrences in this cohort occurred less than 15 months from the initial resection. The authors recommend intraoperative angiography to help ensure complete resection at the time of the surgery. Follow-up vascular imaging is crucial for detecting recurrent AVMs, and conventional angiography is preferred because MRA can miss smaller AVMs. One-year follow-up imaging detected these recurrences, and no one who had negative results on an angiogram obtained at 1 year had a late recurrence. However, not all of the patients have been followed for 5 years or until 18 years of age, so longer follow-up is required for these patients. A lower compactness score predicted recurrent AVM in this cohort.
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Affiliation(s)
- Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania Medical Center, PA, USA.
| | | | - Robert L. Bailey
- Department of Neurosurgery, University of Pennsylvania Medical Center,Division of Neurosurgery, Children’s Hospital of Philadelphia
| | | | - Joanna Ekstrom
- Division of Neurosurgery, Children’s Hospital of Philadelphia,School of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Gregory G. Heuer
- Department of Neurosurgery, University of Pennsylvania Medical Center,Division of Neurosurgery, Children’s Hospital of Philadelphia
| | - Phillip B. Storm
- Department of Neurosurgery, University of Pennsylvania Medical Center,Division of Neurosurgery, Children’s Hospital of Philadelphia
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Nair AP, Kumar R, Mehrotra A, Srivastava AK, Sahu RN, Nair P. Clinical, radiological profile and outcome in pediatric Spetzler-Martin grades I-III arteriovenous malformations. Childs Nerv Syst 2012; 28:593-8. [PMID: 22270650 DOI: 10.1007/s00381-011-1668-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Treatment of pediatric arteriovenous malformations (AVMs) is always a challenge considering their hemorrhagic presentation, associated morbidity and mortality, and the potential long life span of these children. Spetzler-Martin grades I-III are the grey zones as far as the treatment options are concerned. With a generous multimodality approach, one can reduce the morbidity and mortality to a considerable extent. OBJECTIVE To analyze the demographic and clinico-radiological profile of pediatric intracranial AVMs belonging to Spetzler-Martin grades I-III and their outcome following microsurgical excision. METHODS Pediatric patients (≤18 years of age) from a period of January 2001-January 2011 were included in the study. Patients with associated aneurysms or tumors were excluded from the study. Post-operative DSA/CT angiography was done within 6 weeks after surgery. Outcome was analyzed in terms of neurological improvement according to Medical Research Council Grade (MRC), obliteration of the AVM in post-operative angiography and Modified Rankin score. Outcome based on Modified Rankin score was favorable with a score of 0-2 and unfavorable when the score was 3-6. RESULTS A total of 36 patients with a mean follow-up of 12.75 months were identified. Thirty-one patients (86.1%) presented with hemorrhage while only 15 (41.6%) presented with seizures. There were 25 (69.4%) males and 11 (30.6%) females. Spetzler-Martin grade was grade I in six patients, grade II in 20 patients, and grade III in ten patients. All patients underwent surgical excision of the AVMs and post-operative angiography showed a 100% obliteration rate. There was a favorable outcome in 86.1% of the patients according to modified Rankin score. CONCLUSION The aim of treating a pediatric AVM should be complete obliteration of the AVM considering the high risk of hemorrhage and the morbidity and mortality associated with hemorrhage. With careful planning and adopting a multimodality treatment, complete obliteration can definitely be achieved.
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Affiliation(s)
- Anup P Nair
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
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Darsaut TE, Guzman R, Marcellus ML, Edwards MS, Tian L, Do HM, Chang SD, Levy RP, Adler JR, Marks MP, Steinberg GK. Management of pediatric intracranial arteriovenous malformations: experience with multimodality therapy. Neurosurgery 2011; 69:540-56; discussion 556. [PMID: 21430584 DOI: 10.1227/neu.0b013e3182181c00] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Successful management of pediatric arteriovenous malformations (AVMs) often requires a balanced application of embolization, surgery, and radiosurgery. OBJECTIVE To describe our experience treating pediatric AVMs. METHODS We analyzed 120 pediatric patients (< 18 years of age) with AVMs treated with various combinations of radiosurgery, surgery, and endovascular techniques. RESULTS Between 1985 and 2009, 76 children with low Spetzler-Martin grade (1-3) and 44 with high-grade (4-5) AVMs were treated. Annual risk of hemorrhage from presentation to initial treatment was 4.0%, decreasing to 3.2% after treatment initiation until confirmed obliteration. Results for AVM obliteration were available in 101 patients. Initial single-modality therapy led to AVM obliteration in 51 of 67 low-grade (76%) and 3 of 34 high-grade (9%) AVMs, improving to 58 of 67 (87%) and 9 of 34 (26%), respectively, with further treatment. Mean time to obliteration was 1.8 years for low-grade and 6.4 years for high-grade AVMs. Disabling neurological complications occurred in 4 of 77 low-grade (5%) and 12 of 43 high-grade (28%) AVMs. At the final clinical follow-up (mean, 9.2 years), 48 of 67 patients (72%) with low-grade lesions had a modified Rankin Scale score (mRS) of 0 to 1 compared with 12 of 34 patients (35%) with high-grade AVMs. On multivariate analysis, significant risk factors for poor final clinical outcome (mRS ≥ 2) included baseline mRS ≥ 2 (odds ratio, 9.51; 95% confidence interval, 3.31-27.37; P < .01), left-sided location (odds ratio, 3.03; 95% confidence interval, 1.11-8.33; P = .03), and high AVM grade (odds ratio, 4.35; 95% confidence interval, 1.28-14.28; P = .02). CONCLUSION Treatment of pediatric AVMs with multimodality therapy can substantially improve obliteration rates and may decrease AVM hemorrhage rates. The poor natural history and risks of intervention must be carefully considered when deciding to treat high-grade pediatric AVMs.
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Affiliation(s)
- Tim E Darsaut
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5325, USA
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O'Lynnger TM, Al-Holou WN, Gemmete JJ, Pandey AS, Thompson BG, Garton HJL, Maher CO. The effect of age on arteriovenous malformations in children and young adults undergoing magnetic resonance imaging. Childs Nerv Syst 2011; 27:1273-9. [PMID: 21442267 DOI: 10.1007/s00381-011-1434-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 03/08/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) are the most frequently encountered structural cause of spontaneous intracerebral hemorrhage in childhood, excluding hemorrhages of prematurity. The goal of our study was to examine the relationship between age and AVM prevalence on imaging in children, which to date has not been well described. METHODS We queried the electronic and radiographic records of 14,936 consecutive patients aged 25 years or less who had undergone brain magnetic resonance imaging (MRI) at a single institution over an 11-year period to identify those with a cerebral AVM. We collected age, gender, and other demographic characteristics for all patients. For all patients with a cerebral AVM, we recorded the location, size, drainage pattern, Spetzler-Martin grade, medical history, and presence of neurological symptoms. RESULTS Cerebral AVMs were identified in 55 patients (0.37%). The prevalence of AVMs detected on MRI significantly increased with age (p = 0.001). AVMs were found in 0.34% of boys (25 of 7,447) and 0.40% of girls (30 of 7,489). AVMs were most commonly identified in the frontal lobes (36%), followed by parietal (20%) and temporal lobes (13%). Sixty percent (n = 33) of AVMs were less than 3 cm in size, 35% (n = 19) were 3-6 cm in size, and 5.5% (n = 3) were greater than 6 cm in size. As for Spetzler-Martin grade of the AVMs, 25.5% were grade I, 18.2% were grade II, 36.4% were grade III, 16.4% were grade IV, and 3.6% were grade V. CONCLUSIONS AVMs are seen more frequently on MRI with advancing age in children and young adults.
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Affiliation(s)
- Thomas M O'Lynnger
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109-5338, USA
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Yeon JY, Shin HJ, Kim JS, Hong SC, Lee JI. Clinico-radiological outcomes following gamma knife radiosurgery for pediatric arteriovenous malformations. Childs Nerv Syst 2011; 27:1109-19. [PMID: 21286730 DOI: 10.1007/s00381-011-1401-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 01/19/2011] [Indexed: 01/20/2023]
Abstract
PURPOSE The aim of this study was to evaluate clinico-radiological outcomes following gamma knife radiosurgery (GKS) for pediatric arteriovenous malformations (AVMs). METHODS The present series included 39 children (3-17 years of age) who underwent GKS for cerebral AVMs between January 2002 and February 2008. Twenty-five patients presented with hemorrhages. The median AVM volume was 1.5 cm³, and the median marginal dose was 20 Gy. All patients continued to have follow-up for more than 24 months with serial magnetic resonance images (MRIs)/angiograms. Current school performance has been evaluated using a telephone survey answered by the patients' parents. RESULTS Follow-up angiograms, available in 34 patients, confirmed complete obliteration in 16 patients. Serial MRIs indicated obliteration of the nidus in one of five patients without angiography. The diffuse nidus structure and low marginal dose were significantly associated with incomplete obliteration. Twelve patients underwent a second GKS, and subsequent angiographies, available in six patients, demonstrated complete obliteration in two of them. Complications included new-onset seizures (n = 1), apraxia (n = 1), and temporal horn entrapment requiring a shunt operation (n = 1). School performance declined in 14 out of 32 patients. Both the AVM volume and modified AVM score were found to be reliable predictors of school performance. CONCLUSIONS The results of the present study substantiate the diffuse and other atypical features of pediatric AVMs as major determinants of treatment failure following GKS. Considering the apparent declination of school performance, future prospective studies would be required to investigate the possible late-effects of GKS on neuropsychological function.
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Affiliation(s)
- Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-Gu, Seoul, 135-710, Republic of Korea
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Niazi TN, Klimo P, Anderson RCE, Raffel C. Diagnosis and management of arteriovenous malformations in children. Neurosurg Clin N Am 2011; 21:443-56. [PMID: 20561494 DOI: 10.1016/j.nec.2010.03.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arteriovenous malformation (AVM) is the most common cause of spontaneous intraparenchymal hemorrhage in children, excluding hemorrhages of prematurity and early infancy. Because most children diagnosed with an AVM undergo initial treatment emergently, the natural history of AVMs in the pediatric population is not well understood. Most pediatric AVMs do not come to clinical attention unless they hemorrhage. Therefore, their optimal management remains controversial. Children with intracranial AVMs represent a special challenge in that they harbor unacceptable lifelong risks of hemorrhage and potential neurologic deficits. Patients should be evaluated on a case-by-case basis to determine the best multidisciplinary treatment regimen that can be used to preserve neurologic function and eradicate the AVM with the lowest risk of mortality. Successful treatment depends on the location and size of the AVM, its hemodynamic properties, the clinical condition of the patient, and the treatment modality selected. The armamentarium for AVM management has grown with technological advances and now includes microsurgical resection, endovascular embolization, radiosurgery, or any combination of these modalities. Microsurgical resection remains the gold standard for treatment of accessible pediatric AVMs, especially in cases that present with intracranial hemorrhage. Newer modalities, such as embolization and radiosurgery, have provided additional tools to help children with large or deep-seated lesions that would be deemed unresectable with microsurgical techniques alone. Long-term follow-up with repeated diagnostic imaging is important despite complete obliteration of the lesion to rule out the small possibility of AVM recurrence.
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Affiliation(s)
- Toba N Niazi
- Department of Neurosurgery, Primary Children's Medical Center, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, USA
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Rubin D, Santillan A, Greenfield JP, Souweidane M, Riina HA. Surgical management of pediatric cerebral arteriovenous malformations. Childs Nerv Syst 2010; 26:1337-44. [PMID: 20596869 DOI: 10.1007/s00381-010-1211-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 06/12/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are the most common cause of intracerebral hemorrhage in children. Different options exist for their successful management consisting of surgery, endovascular embolization, stereotactic radiosurgery, or a combination of these treatments. DISCUSSION In this paper, we discuss the different treatment modalities in the treatment of pediatric cerebral AVMs emphasizing the role of surgery and endovascular embolization as a preoperative strategy.
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Affiliation(s)
- David Rubin
- Department of Neurological Surgery,Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Multimodality treatment of cerebral AVMs in children: a single-centre 20 years experience. Childs Nerv Syst 2010; 26:681-7. [PMID: 19946691 DOI: 10.1007/s00381-009-1039-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to review our experience with a multimodality treatment approach in the management of cerebral arteriovenous malformation (AVM) in children. METHODS We retrospectively analysed a consecutive series of 56 children who harboured a cerebral AVM and were treated at our institution between 1988 and 2008. During the whole treatment period, a combined treatment strategy, including microsurgery, endovascular treatment and gamma knife radiosurgery, was used. RESULTS Of the 56 patients (median age, 14.0; range, 3 months-18 years) reported, 36 (64.3%) were admitted after AVM rupture; of these, only one AVM (1.8%) was considered untreatable. In 30.9% (17/55) of the treated patients, a single treatment measure was sufficient to attain angiographic cure of the AVM. Among these, six patients (10.9%) had microsurgical AVM resection, four patients (7.3%) underwent endovascular treatment, and another seven patients (12.7%) underwent radiosurgical management of the AVM. The majority of the population (38/55; 69.1%) underwent combined treatment: 21 patients (38.2%) received embolisation followed by radiosurgery of the remnant nidus, ten patients (18.2%) underwent embolisation with subsequent surgical resection of the residual AVM, three patients (5.5%) had radiosurgery after incomplete surgical AVM nidus resection and another four patients (7.3%) required a combination of all three treatment modalities to achieve permanent angiographic cure of the AVM. We observed good clinical outcomes (Glasgow Outcome Scale 5 and 4) in 94.6% of the children. Complete angiographic obliteration was achieved in 93.3% of the patients treated. CONCLUSION A multimodality treatment approach in children harbouring cerebral AVMs leads to excellent angiographic and clinical outcomes.
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