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Yang T, Liu Y, Yuan B, Han Y, Xiang Y, Sun J, Guo W, Chen M, Wang H. Three-Pillar Expansive Craniotomy in Children with Acute Ruptured Supratentorial Brain Arteriovenous Malformations. World Neurosurg 2024; 189:e347-e354. [PMID: 38878889 DOI: 10.1016/j.wneu.2024.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/09/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Acute rupture and hemorrhage of pediatric brain arteriovenous malformations (AVMs) may lead to cerebral herniation or intractable intracranial hypertension, necessitating emerging surgical interventions to alleviate intracranial pressure. However, there is still controversy regarding the timing of treatment for ruptured AVMs. This study aimed to assess the feasibility of utilizing three-pillar expansive craniotomy (3PEC) at different times during the treatment of pediatric ruptured supratentorial AVMs. METHODS A retrospective analysis was conducted on all consecutive cases of acute rupture in supratentorial AVM children who underwent 3PEC at a single institution from 2020 to 2022. General information, clinical characteristics, radiological data, and prognosis were reviewed and analyzed. RESULTS Thirteen children were included in the analysis. The intracranial pressure of all patients decreased to below 15 mmHg within 10 days. The expansion volume of the cranial cavity of the patients increased by 18.3 cm3 (95% confidence interval, 10.2-26.3; P < 0.001) compared to the hematoma volume. None of the patients required decompressive craniectomy due to intractable intracranial hypertension caused by cerebral swelling. The median waiting period for patients with delayed AVMs treatment was 8 days, during which no rebleeding occurred. CONCLUSIONS Emergency intervention with 3PEC in children experiencing acutely ruptured supratentorial AVMs appears to be feasible. For children requiring delayed management of the AVMs, 3PEC may diminish the risk of rebleeding during the waiting period and shorten the waiting period.
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Affiliation(s)
- Tianquan Yang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yuchen Liu
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Bin Yuan
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yongjun Xiang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jingxuan Sun
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wanliang Guo
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Min Chen
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
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Flores-Milan G, Rainone GJ, Peto I, Vakharia KV, Guerrero WR, Mokin M, Hartnett SM, Agazzi S. Timing of Embolization, Radiosurgery, and Resection of Arteriovenous Malformations in Pediatric Patients: A Retrospective, Descriptive Study. World Neurosurg 2024:S1878-8750(24)01301-9. [PMID: 39074586 DOI: 10.1016/j.wneu.2024.07.161] [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: 02/11/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Cerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization, and stereotactic radiosurgery. There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/stereotactic radiosurgery and resection is not well explored in the literature. We present a series of pediatric patients with AVMs, with special attention directed to the timing of treatment. METHODS Electronic medical records of all pediatric patients (<18 years old at treatment) with AVMs treated at our institution were retrospectively reviewed after institutional review board approval. Demographic information, AVM characteristics, treatment variables, and outcomes were recorded. RESULTS In our cohort of 27 patients, 21 (77.8%) presented with a ruptured AVM. Of these patients, 6 (28.6%) had a Glasgow Coma Scale score of 3-10 and underwent treatment within 24 hours of presentation, and 10 (47.6%) with a Glasgow Coma Scale score of 12-15 were treated between 24 and 120 hours after presentation. The remaining 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. Regardless of rupture status, 96% of our cohort had a modified Rankin Scale score of 1-2 at most recent follow-up. CONCLUSIONS We present our institution's experience with pediatric AVMs, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status.
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Affiliation(s)
- Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Gersham J Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Kunal V Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Waldo R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Sara M Hartnett
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
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Iampreechakul P, Wangtanaphat K, Wattanasen Y, Hangsapruek S, Lertbutsayanukul P, Siriwimonmas S. Long-term surveillance in an infant with spontaneous obliteration of pial arteriovenous malformation and large intranidal aneurysm: A unique case observation. Surg Neurol Int 2024; 15:206. [PMID: 38974548 PMCID: PMC11225396 DOI: 10.25259/sni_45_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/23/2024] [Indexed: 07/09/2024] Open
Abstract
Background Spontaneous obliteration of untreated cerebral arteriovenous malformations (AVMs) is rare, occurring in <1% of cases, and is even less common in pediatric populations. The mechanisms driving spontaneous regression of brain AVMs remain poorly understood, and long-term surveillance in pediatric patients is infrequently documented. Case Description The authors reported a remarkably rare instance of spontaneous thrombosis in a pial AVM accompanied by a large intranidal aneurysm in a 10-month-old infant, initially presenting with a nocturnal seizure. Diagnostic imaging revealed a ruptured intranidal aneurysm causing acute hemorrhage in the left anterior interhemispheric subdural space, extending into adjacent areas. Further, magnetic resonance imaging (MRI) and magnetic resonance angiography delineated the AVM in the left superior frontal gyrus, associated with a thrombosed aneurysm and surrounding edema. Cerebral angiography confirmed the AVM's origin from the left anterior cerebral artery, displaying early venous drainage and small, indirect feeders not amenable to endovascular treatment. Over time, serial imaging showed the aneurysm's transition from partial to complete thrombosis. Subsequent MRIs and angiographic assessments up to age 10 confirmed complete resolution of the AVM and aneurysm, with focal hyperemia persisted until age 16, when recurrent AVM was identified. Conclusion We document a rare spontaneous regression of a pial AVM with an intranidal aneurysm influenced by specific vascular factors. Despite this, spontaneous thrombosis should not replace vigilant long-term monitoring in pediatric neurovascular care.
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Affiliation(s)
| | | | - Yodkhwan Wattanasen
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand
| | - Sunisa Hangsapruek
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand
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See AP, Smith ER. Management of Pediatric Intracranial Arteriovenous Malformations. J Korean Neurosurg Soc 2024; 67:289-298. [PMID: 38433517 PMCID: PMC11079567 DOI: 10.3340/jkns.2024.0027] [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: 01/23/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Pediatric intracranial arteriovenous malformations (AVMs) are challenging lesions managed by pediatric neurosurgeons. The high risk of hemorrhage and neurologic injury is compounded by the unique anatomy of each malformation that requires individualizing treatment options. This article reviews the current status of pediatric AVM epidemiology, pathophysiology and clinical care, with a specific focus on the rationale and methodology of surgical resection.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Yuan K, Chen Y, Yan D, Li R, Li Z, Zhang H, Wang K, Han H, Zhao Y, Ma L, Hao Q, Ye X, Jin H, Meng X, Liu A, Gao D, Sun S, Kang S, Wang H, Li Y, Wang S, Chen X, Zhao Y. Re-rupture in ruptured brain arteriovenous malformations: a retrospective cohort study based on a nationwide multicenter prospective registry. J Neurointerv Surg 2023:jnis-2023-020650. [PMID: 37903561 DOI: 10.1136/jnis-2023-020650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND This study aimed to investigate the natural history of re-rupture in ruptured brain arteriovenous malformations (AVMs) and to provide comprehensive insights into its associated factors and prevention. METHODS This study included 1712 eligible ruptured AVMs from a nationwide multicenter prospective collaboration registry between August 2011 and September 2021. The natural rupture risk before intervention and the annual rupture risk after intervention were both assessed. Cox proportional hazard regression models and Kaplan-Meier survival curves were used to explore independent factors associated with AVM re-rupture. The correlation between these factors and AVM re-rupture was verified in multiple independent cohorts, and the prevention effect of intervention timing and intervention strategies on AVM re-rupture was further analyzed. RESULTS The annual re-rupture risk in ruptured AVMs was 7.6%, and the cumulative re-rupture risk in the first 1, 3, 5, and 10 years following the initial rupture were 10%, 25%, 37.5%, and 50%, respectively. Cox proportional hazard regression analysis confirmed adult patients, ventricular system involvement, and any deep venous drainage as independent factors associated with AVM re-rupture. The intervention was found to significantly reduce the risk of AVM re-rupture (annual rupture risk 11.34% vs 1.70%, p<0.001), especially in those who underwent surgical resection (annual rupture risk 0.13%). CONCLUSIONS The risk of re-rupture in ruptured AVMs is high. Adult patients, ventricular system involvement, and any deep venous drainage are independent risk factors for re-rupture. Applying the results universally to all ruptured AVM cases may be biased. Intervention could effectively reduce the risk of re-rupture.
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Affiliation(s)
- Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
- Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Ali Liu
- Department of Gamma-Knife center, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife center, Beijing Tiantan Hospital, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife center, Beijing Tiantan Hospital, Beijing, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Capital Medical University, Beijing, Fengtai District, China
- Beijing Engineering Research Center, Beijing, Fengtai District, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
- Beijing Neurosurgical Institute, Beijing, China
- Beijing Engineering Research Center, Beijing, Fengtai District, China
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See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA.
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7
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Aziz N, Duddy JC, Saeed D, Hennigan D, Israni A, Puthuran M, Chandran A, Mallucci C. Multi-modality treatment approach for paediatric AVMs with quality-of-life outcome measures. Childs Nerv Syst 2023; 39:2439-2447. [PMID: 37198451 DOI: 10.1007/s00381-023-05954-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Despite the potentially devastating and permanently disabling effects of paediatric arteriovenous malformations (pAVMs), there is a paucity of studies reporting long-term quality-of-life (QoL) outcomes in AVM patients. We aim to evaluate the management strategies for paediatric intracranial pAVMs in the UK and long-term QoL outcomes using a validated paediatric quality-of-life outcome measure. METHODS In this single-centre case-series, we retrospectively reviewed a prospectively maintained database of all paediatric patients (i.e. 0-18 years old) with intracranial AVMs, who were managed at Alder Hey Children's Hospital from July 2007 to December 2021. We also collected the PedsQL 4.0 score for these patients as a measure of QoL. RESULTS Fifty-two AVMs were included in our analysis. Forty (80%) were ruptured, 8 (16%) required emergency intervention, 17 (35%) required elective surgery, 15 (30%) underwent endovascular embolisation, and 15 (30%) patients underwent stereotactic radiosurgery. There was an 88% overall obliteration rate. Two (4%) pAVMs rebled, and there were no mortalities. Overall, the mean time from diagnosis to definitive treatment was 144 days (median 119; range 0-586). QoL outcomes were collected for 26 (51%) patients. Ruptured pAVM presentation was associated with worse QoL (p = 0.0008). Location impacted psychosocial scores significantly (71.4, 56.9, and 46.6 for right supratentorial, left supratentorial, and infratentorial, respectively; p = 0.04). CONCLUSION This study shows a staged multi-modality treatment approach to pAVMs is safe and effective, with superior obliteration rates with surgery alone. QoL scores are impacted by AVM presentation and location regardless of treatment modality.
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Affiliation(s)
- Natasha Aziz
- School of Medicine, University of Liverpool, Liverpool, UK.
| | - John C Duddy
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Danial Saeed
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Dawn Hennigan
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Anil Israni
- Department of Neurology, AlderHey Children's NHS Foundation Trust, Liverpool, UK
| | - Mani Puthuran
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Arun Chandran
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Conor Mallucci
- Department of Neurosurgery, AlderHey Children's NHS Foundation Trust, Liverpool, UK
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8
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Zhu H, Liu L, Chang Y, Song Y, Liang S, Ma C, Zhang L, Liang F, Jiang C, Zhang Y. Quantitative evaluation of the subsequent hemorrhage with arteriography-derived hemodynamic features in patients with untreated cerebral arteriovenous malformation. Front Neurol 2023; 14:1174245. [PMID: 37654429 PMCID: PMC10466408 DOI: 10.3389/fneur.2023.1174245] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023] Open
Abstract
Background Patients with untreated cerebral arteriovenous malformations (AVMs) are at risk of intracerebral hemorrhage. However, treatment to prevent AVM hemorrhage carries risks. Objective This study aimed to analyze the AVM nidus-related hemodynamic features and identify the risk factors for subsequent hemorrhage. Methods We retrospectively identified patients with untreated AVMs who were assessed at our institution between March 2010 and March 2021. Patients with ≥6 months of treatment-free and hemorrhage-free follow-up after diagnosed by digital subtraction angiography were included in subsequent examinations. The hemodynamic features were extracted from five contrast flow-related parameter maps. The Kaplan-Meier analyses and Cox proportional hazards regression models were used to find the potential risk factors for subsequent hemorrhage. Results Overall, 104 patients with a mean follow-up duration of 3.37 years (median, 2.42 years; range, 6-117 months) were included in study, and the annual risk of rupture was 3.7%. Previous rupture (hazard ratio [HR], 4.89; 95% confidence interval [CI], 1.16-20.72), deep AVM location (HR, 4.02; 95% CI, 1.01-15.99), higher cerebral blood volume (HR, 3.35; 95% CI, 1.15-9.74) in the nidus, and higher stasis index (HR, 1.54; 95% CI, 1.06-2.24) in the nidus were associated with subsequent hemorrhage in untreated AVMs. Conclusion Higher cerebral blood volume and stasis index in the nidus suggest increased blood inflow and stagnant blood drainage. The combination of these factors may cause subsequent hemorrhage of AVMs.
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Affiliation(s)
- Haoyu Zhu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuzhou Chang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuqi Song
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Chao Ma
- Department of Neurosurgery, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Longhui Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Liang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Chuhan Jiang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Järvelin P, Pekonen H, Koivisto T, Frösen J. Recurrence of arteriovenous malformations of the brain after complete surgical resection. Kuopio University Hospital experience and systematic review of the literature. Neurosurg Rev 2023; 46:99. [PMID: 37119280 PMCID: PMC10148763 DOI: 10.1007/s10143-023-02001-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/31/2023] [Accepted: 04/08/2023] [Indexed: 05/01/2023]
Abstract
Treatment for arteriovenous malformations of the brain (bAVMs) aims to achieve complete removal or occlusion of the lesion in order to eradicate the risk of rupture and subsequent morbidity associated with these lesions. Despite initially successful treatment, bAVMs may carry a risk of recurrence especially in younger patients. We studied the rate of recurrence of surgically treated bAVMs at Kuopio University Hospital (KUH) in 1981-2021. The study population was collected retrospectively from KUH databases and presented a cohort of 135 surgically treated bAVMs with complete occlusion of the lesion. We also performed a systematic literature review on this topic. In our series, 6 out of 135 (4.4%) patients with angiographically confirmed removal of the lesion later developed a recurrent bAVM with a median time to diagnosis of recurrence of 7.46 years. In pediatric patients, the rate was 5 out of 17 (29.4%). bAVM recurrence was associated with age (p = 0.001) and initial hemorrhagic presentation (p = 0.039). Median age of the study population was 37 years (min 0, max 70), and 51/135 (37.8%) of the patients were female. Seventeen (12.6%) of the 135 bAVM patients were considered pediatric (18 years old or younger) at the time of the operation. In the literature review, 79 of 1739 (4.5%) of surgically treated patients later developed a recurrence with a mean delay of 3.1 years until diagnosis of recurrence. Young surgically treated bAVM patients with a hemorrhagic presentation at initial diagnosis are at a relatively high risk of bAVM recurrence. Follow-up imaging should be arranged for these patients in order to prevent rupture from a recurrent bAVM and subsequent morbidity.
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Affiliation(s)
- Patrik Järvelin
- Hemorrhagic Brain Pathology Research Group, Kuopio University Hospital and Tampere University, Tampere, Finland
| | - Henri Pekonen
- Hemorrhagic Brain Pathology Research Group, Kuopio University Hospital and Tampere University, Tampere, Finland
| | - Timo Koivisto
- Dept of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Juhana Frösen
- Hemorrhagic Brain Pathology Research Group, Kuopio University Hospital and Tampere University, Tampere, Finland.
- Dept of Neurosurgery, Tampere University Hospital, Tampere, Finland.
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10
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Rodriguez-Calienes A, Vivanco-Suarez J, Costa M, Echevarria-Quispe JY, Rodríguez-Varela R, Ortega-Gutierrez S, Saal-Zapata G. Embolization as stand-alone strategy for pediatric low-grade brain arteriovenous malformations. J Stroke Cerebrovasc Dis 2023; 32:107137. [PMID: 37068327 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107137] [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: 01/25/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES We evaluated the safety and efficacy of endovascular embolization as first-line stand-alone strategy for the treatment of low-grade brain arteriovenous malformations (bAVMs) (Spetzler Martin [SM] grade I and II) in pediatric patients. In addition, we assessed the predictors of procedure-related complications and radiographic complete obliteration in a single session. MATERIAL AND METHODS We conducted a single center retrospective cohort study of all pediatric (≤18 years) patients who underwent embolization as a stand-alone strategy for low-grade bAVMs between 2010 and 2022. Safety was measured by procedure-related complications and mortality. Efficacy was defined as complete angiographic obliteration after the last embolization session. RESULTS Sixty-eight patients (41 females; median age 14 years) underwent a total of 102 embolization sessions. There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Six procedure-related complications (5.8% of procedures) were observed and no deaths were reported. All the complications were intraoperative nidus ruptures. A single draining vein was the only significant predictor of procedure-related complications (OR=0.10; 95% CI 0.01 - 0.72; p=0.048). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (51%) the bAVM was completely occluded in one session. The bAVM nidal size was a predictor of complete obliteration in one session (OR=0.44; 95% CI, 0.21-0.80; p=0.017). CONCLUSION Endovascular treatment as a stand-alone strategy for pediatric low-grade bAVMs is an adequate first-line approach in high volume centers with endovascular expertise. Nidal size evaluation is relevant in order to optimize patient selection for embolization as a stand-alone treatment modality.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA
| | - Matias Costa
- Cerebrovascular Neurosurgery Department, Swedish Neuroscience Institute, Seattle, WA, USA
| | | | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA; Department of Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
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11
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Kilian A, Latino GA, White AJ, Ratjen F, McDonald J, Whitehead KJ, Gossage JR, Krings T, Lawton MT, Kim H, Faughnan ME. Comparing Characteristics and Treatment of Brain Vascular Malformations in Children and Adults with HHT. J Clin Med 2023; 12:2704. [PMID: 37048789 PMCID: PMC10094792 DOI: 10.3390/jcm12072704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease characterized by the development of vascular malformations (VMs) in organs such as the brain and lungs, as well as telangiectases on mucosal surfaces. Prophylactic treatment of organ VMs may prevent potential complications, such as hemorrhage. However, brain VM treatment-surgical resection, embolization, and/or radiosurgery-is not recommended for all patients due to the associated risks. Given the scarcity of data regarding HHT-related brain VM presentation and treatment trends in pediatric patients, we aim to describe the clinical presentations and the patterns of treatment of HHT-related brain VMs in a pediatric cohort, and compare pediatric trends to those of adults. Demographic and clinical data were analyzed in 114 pediatric patients with HHT-related brain VMs and compared with a cohort of 253 adult patients enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. Our data demonstrated that a higher proportion of pediatric patients with HHT-related brain VMs were symptomatic at presentation (p = 0.004). Moreover, a higher proportion of pediatric patients presented with intracranial hemorrhage (p < 0.001) and seizure (p = 0.002) compared to adult patients. Surgical resection was the most common brain VM treatment modality in both children and adults. We conclude that pediatric patients may be more likely to present with symptoms and complications from brain VMs, supporting the case for screening for brain VMs in children with HHT.
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Affiliation(s)
- Alexandra Kilian
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
| | - Giuseppe A. Latino
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, ON M2K 1E1, Canada
| | - Andrew J. White
- Department of Pediatrics, St Louis University, St. Louis, MO 63103, USA
| | - Felix Ratjen
- Division of Respiratory Medicine and Translational Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT 84132, USA
| | - Kevin J. Whitehead
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT 84132, USA
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT 84132, USA
| | - James R. Gossage
- Department of Medicine, Augusta University, Augusta, GA 30912, USA
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94110, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Marie E. Faughnan
- Toronto HHT Centre, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON M5B 1W8, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
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Rodriguez-Calienes A, Vivanco-Suarez J, Borjas-Calderón NF, Chavez-Ecos FA, Fernández DEM, Malaga M, Basilio Flores JE, Ortega-Gutierrez S, Saal-Zapata G. Curative embolization of ruptured pediatric cerebral arteriovenous malformations. Clin Neurol Neurosurg 2023; 227:107663. [PMID: 36868088 DOI: 10.1016/j.clineuro.2023.107663] [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: 11/28/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Embolization with the intention to cure has not been well studied in ruptured arteriovenous malformations (AVMs). Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization of ruptured pediatric AVMs and assess predictors of obliteration and complications. METHODS A retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization of ruptured AVMs was conducted in two institutions between 2010 and 2022. The efficacy (complete angiographic obliteration after the last embolization session), recurrence (radiological recurrence of the lesion after confirmed obliteration in follow-up imaging), and safety (procedure-related complications and mortality) of the procedure were evaluated. RESULTS Sixty-eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. Median follow-up time was 18 months after embolization (ranged from 2 to 47 months). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. Recurrence of a totally embolized lesion occurred in 9 patients (13%). Thirteen complications (11.9% of procedures) were observed, and no deaths were reported. A nidus size > 2 cm was the only independent predictor of complete obliteration (OR = 0.16; 95% CI 0.03 - 0.77; p = 0.030). CONCLUSION Embolization of pediatric ruptured AVMs with curative intent can achieve acceptable obliteration rates. However, recurrence after complete obliteration and procedure-related complications of curative embolization of these lesions cannot be ignored. Ruptured AVMs ≤ 2 cm are adequate to achieve complete obliteration with curative endovascular management.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nagheli Fernanda Borjas-Calderón
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru
| | - Fabian A Chavez-Ecos
- Sociedad Científica de Estudiantes de Medicina de Ica, Universidad Nacional San Luis Gonzaga, Ica, Peru; Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | | | - Marco Malaga
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service. Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru.
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Sattari SA, Yang W, Xu R, Feghali J, Tamargo RJ, Huang J. Natural history and treatment of deep-seated brain arteriovenous malformations in pediatric patients. J Neurosurg Pediatr 2022; 30:578-585. [PMID: 36087319 DOI: 10.3171/2022.8.peds22213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric deep brain arteriovenous malformations (bAVMs) represent a unique management challenge given their higher cumulative risk of hemorrhage as well as a higher risk of treatment. Better understanding of hemorrhage risk in this patient population will lead to a better decision-making process for patient management. METHODS The authors retrospectively reviewed their institutional bAVM database from 1990 to 2019 and included patients younger than 21 years who had deep-seated bAVMs. They present the annual hemorrhage risk, during the natural history and after treatment, and functional outcomes. RESULTS Thirty-one pediatric patients were included in this study (13 males and 18 females) with a mean age of 11.8 (SD 4.4) years. The most frequent presenting symptoms were headache (54.8%), weakness (38.7%), and seizure (22.6%). The mean follow-up duration was 13.14 (SD 12.5) years, during which 7 (22.6%) AVMs were obliterated, 10 (32.3%) individuals experienced hemorrhage, and the modified Rankin Scale score worsened in 8 (25.8%) patients. The annual natural history risk of hemorrhage was 3.24% per patient, and the overall annual hemorrhage risk after treatment was 1.98% per patient. In particular, the risk was reduced to 0.64% per patient in the stereotactic radiosurgery (SRS) group. Non-White race showed a trend of higher rupture at presentation (OR 5 [95% CI 0.84-41.68], p = 0.09). Female sex was associated with higher odds (OR 13.076 [95% CI 1.424-333.591], p = 0.048) and SRS was associated with lower odds (OR 0.122 [95% CI 0.011-0.862], p = 0.049) of follow-up hemorrhage. CONCLUSIONS Given the substantial cumulative risk of lifelong hemorrhagic stroke in pediatric patients, timely definitive treatment is warranted. SRS may be beneficial when the risk-benefit profile is deemed acceptable.
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Matsumoto Y, Nagata Y, Nakagawa S, Hashikawa T, Sakai H, Takahashi S, Hashimoto Y, Goto S, Sugita Y, Takahashi K. New aneurysm formation and regrowth associated with rebleeding of residual pediatric ruptured arteriovenous malformation: patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22205. [PMID: 36317238 PMCID: PMC9624159 DOI: 10.3171/case22205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND If complete obliteration of ruptured pediatric arteriovenous malformation (AVM) cannot be achieved, the appropriate follow-up duration and predictors of rebleeding remain unknown. OBSERVATIONS Pediatric patients with ruptured AVMs admitted to the authors' hospital within the past 30 years were evaluated. Rebleeding was confirmed in two patients. The first patient was a 5-year-old boy who experienced right thalamic hemorrhage. AVM was found in the bilateral thalamus and treated with stereotactic radiosurgery (SRS). New aneurysm formation and residual AVM regrowth were confirmed 21 years after the SRS. Eight months later, rebleeding occurred. The second patient was a 5-year-old boy who underwent removal of a left cerebellar hemorrhage and AVM. The residual AVM was treated with SRS. Residual AVM regrowth was detected at 6 years 7 months after SRS. Five months later, new aneurysm formation was confirmed. Two additional days later, rebleeding occurred. LESSONS New aneurysm formation and residual AVM regrowth may predict rebleeding and can occur >20 years after the initial rupture and treatment. If AVM obliteration is not achieved, long-term follow-up is needed, even in adulthood, with attention to new aneurysm formation and residual AVM regrowth. Further treatment is recommended if these findings are confirmed.
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Affiliation(s)
| | - Yui Nagata
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Setsuko Nakagawa
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Takuro Hashikawa
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Hideki Sakai
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Shinji Takahashi
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Yosuke Hashimoto
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Shin Goto
- Department of Neurosurgery, Tanushimaru Central Hospital, Fukuoka, Japan
| | - Yasuo Sugita
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
| | - Kenji Takahashi
- Department of Neurosurgery, St. Mary’s Hospital, Fukuoka, Japan; and
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Clinical Characteristics and Multimodality Therapy Outcomes in 304 Pediatric Patients with Cerebral Arteriovenous Malformations. World Neurosurg 2022; 168:e150-e161. [DOI: 10.1016/j.wneu.2022.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022]
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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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Oushy S, Gilder HE, Nesvick CL, Lanzino G, Pollock BE, Daniels DJ, Ahn ES. Delayed recurrence of pediatric arteriovenous malformations after radiologically confirmed obliteration. J Neurosurg Pediatr 2022; 30:195-202. [PMID: 35623369 DOI: 10.3171/2022.4.peds21471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) are a major cause of intracerebral hemorrhage in children, resulting in significant morbidity and mortality. Moreover, the rate of AVM recurrence in children is significantly higher than in adults. The aim of this study was to define the risk of delayed pediatric AVM (pAVM) recurrence following confirmed radiological obliteration. Further understanding of this risk could inform the role of long-term radiological surveillance. METHODS The authors conducted a retrospective review of ruptured and unruptured pAVM cases treated at a single tertiary care referral center between 1994 and 2019. Demographics, clinical characteristics, treatment modalities, and AVM recurrence were analyzed. RESULTS A total of 102 pediatric patients with intracranial AVMs, including 52 (51%) ruptured cases, were identified. The mean patient age at presentation was 11.2 ± 4.4 years, and 51 (50%) patients were female. The mean nidus size was 2.66 ± 1.44 cm. The most common Spetzler-Martin grades were III (32%) and II (31%). Stereotactic radiosurgery was performed in 69.6% of patients. AVM obliteration was radiologically confirmed in 68 (72.3%) of 94 patients with follow-up imaging, on angiography in 50 (73.5%) patients and on magnetic resonance imaging in 18 (26.5%). AVM recurrence was identified in 1 (2.3%) of 43 patients with long-term surveillance imaging over a mean follow-up of 54.7 ± 38.9 months (range 2-153 months). This recurrence was identified in a boy who had presented with a ruptured AVM and had been surgically treated at 5 years of age. The AVM recurred 54 months after confirmed obliteration on surveillance digital subtraction angiography. Two other cases of presumed AVM recurrence following resection in young children were excluded from recurrence analysis because of incomplete sets of imaging available for review. CONCLUSIONS AVM recurrence following confirmed obliteration on imaging is a rare phenomenon, though it occurs more frequently in the pediatric population. Regular long-term follow-up with dedicated surveillance angiography is recommended even after obliteration following resection.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurologic Surgery
- 3Radiology, Mayo Clinic, Rochester, Minnesota
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Multimodality Treatment of Brain Arteriovenous Malformations with One-Staged Hybrid Operation: Clinical Characteristics and Long-Term Prognosis. DISEASE MARKERS 2022; 2022:2559004. [PMID: 35265225 PMCID: PMC8898859 DOI: 10.1155/2022/2559004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/19/2022] [Accepted: 02/04/2022] [Indexed: 11/17/2022]
Abstract
Objective We aimed to evaluate the clinical characteristics and long-term prognosis of brain arteriovenous malformations (bAVMs) treated with multimodality management of one-staged hybrid operation. Methods We identified bAVM patients treated with one-staged hybrid operation from a multicenter prospective cohort study (NCT03774017) between January 2016 and June 2020. Patients were divided into unruptured and ruptured groups by the hemorrhagic presentation. Long-term (>12 months) neurological disability, postoperative complications of stroke, and nidus obliteration were evaluated and compared between groups. Prognostic predictors associated with outcomes were analyzed. Results A total of 130 patients were identified in the study receiving one-staged hybrid operations, including 61 unruptured cases and 69 ruptured cases. Mean age was 29.1 years old, with 78 (60.0%) being male. Patients included in the study were followed up for a mean period of 37.4 (11.07) months. The annual hemorrhagic risk was 4.2% per year. Thirteen postoperative stroke events were detected in 11 patients (8.5%). Long-term disability occurred in 6.9% of cases, and 86.2% of patients experienced an unchanged or improved neurological status at the last follow-up. All patients achieved complete obliteration on follow-up angiographies. Increased AVM volume was associated with a higher risk of postoperative stroke (odds ratio (OR) 1.021, 95% confidence interval (CI) 1.006-1.037, and P = 0.006). Poor neurological status (OR 6.461, 95% CI 1.309-31.889, and P = 0.022) and infratentorial location (OR 5.618, 95% CI 1.158-27.246, and P = 0.032) were independent predictors for long-term disability. Conclusions One-staged hybrid operation of embolization combined microsurgical resection can be performed as a safe and effective strategy for bAVM treatments. Long-term prognosis of complete obliteration with low rates of morbidity and mortality can be achieved. Unruptured and ruptured bAVMs acquired similar favorable outcomes after the multimodality treatment.
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Garcia JH, Rutledge C, Winkler EA, Carrete L, Morshed RA, Lu AY, Saggi S, Fox CK, Fullerton HJ, Kim H, Cooke DL, Hetts SW, Lawton MT, Gupta N, Abla AA. Validation of the Ruptured Arteriovenous Malformation Grading Scale in a pediatric cohort. J Neurosurg Pediatr 2022; 29:575-579. [PMID: 35213838 DOI: 10.3171/2022.1.peds21466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric brain arteriovenous malformations (AVMs) are the leading cause of spontaneous intracranial hemorrhage (SICH) in children. Although the incidence of SICH is low in pediatric populations, such events cause substantial morbidity. The recently created Ruptured Arteriovenous Malformation Grading Scale (RAGS) is proposed as a reliable and novel grading system to specifically serve as a predictor of clinical outcomes in patients following AVM rupture, similar to the Hunt and Hess (HH) grade for ruptured aneurysms. While these data are promising, pediatric patients were notably absent from the original study validating the RAGS. Therefore, correlation of the RAGS score with clinical outcomes following AVM rupture in individuals younger than 18 years of age using the RAGS score is needed. The objective of this study was to validate the RAGS in a cohort of pediatric patients with AVMs who presented with hemorrhage, thereby demonstrating the score's generalizability, and expanding its external validity. METHODS A cohort of children with ruptured AVMs were retrospectively reviewed. Using disability, measured by the modified Rankin Scale (mRS), as the response variable, the area under the receiver operating characteristic curve (AUROC) was calculated for patients based on their RAGS scores for three time periods. The AUROC values were then compared with those generated by two commonly used clinical grading systems, the HH classification and Glasgow Coma Scale. RESULTS A total of 81 children who presented with ruptured AVMs were included in the study, with a mean follow-up duration of 4 years. The RAGS score outperformed other clinical grading scales in predicting mRS scores, with AUROC values of 0.81, 0.82, and 0.81 at three distinct follow-up periods. CONCLUSIONS The RAGS score correlated well with the clinical outcome after AVM rupture in pediatric patients. Additional validation studies across multiple treatment centers are needed to further demonstrate the generalizability of the scoring system.
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Affiliation(s)
- Joseph H Garcia
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Caleb Rutledge
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Luis Carrete
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Alex Y Lu
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Satvir Saggi
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Christine K Fox
- 2Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, 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
| | - Steven W Hetts
- 4Department of Radiology and Biomedical Imaging, University of California, San Francisco
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California, San Francisco.,5Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California, San Francisco.,6Department of Pediatrics, University of California, San Francisco, California; and
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California, San Francisco
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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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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; 28:677-684. [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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22
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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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23
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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, Blauwblomme T, Naggara O. Arterial Spin Labeling for the Etiological Workup of Intracerebral Hemorrhage in Children. Stroke 2021; 53:185-193. [PMID: 34517772 DOI: 10.1161/strokeaha.120.032690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Pediatric nontraumatic intracerebral hemorrhage accounts for half of stroke in children. Early diagnostic of the causative underlying lesion is the first step toward prevention of hemorrhagic recurrence. We aimed to investigate the performance of arterial spin labeling sequence (ASL) in the acute phase etiological workup for the detection of an arteriovenous shunt (AVS: including malformation and fistula), the most frequent cause of pediatric nontraumatic intracerebral hemorrhage. METHODS Children with a pediatric nontraumatic intracerebral hemorrhage between 2011 and 2019 enrolled in a prospective registry were retrospectively included if they had undergone ASL-magnetic resonance imaging before any etiological treatment. ASL sequences were reviewed using cerebral blood flow maps by 2 raters for the presence of an AVS. The diagnostic performance of ASL was compared with admission computed tomography angiography, other magnetic resonance imaging sequences including contrast-enhanced sequences and subsequent digital subtraction angiography. RESULTS A total of 121 patients with pediatric nontraumatic intracerebral hemorrhage were included (median age, 9.9 [interquartile range, 5.8-13]; male sex 48.8%) of whom 76 (63%) had a final diagnosis of AVS. Using digital subtraction angiography as an intermediate reference, visual ASL inspection had a sensitivity and a specificity of, respectively, 95.9% (95% CI, 88.5%-99.1%) and 79.0% (95% CI, 54.4%-94.0%). ASL had a sensitivity, specificity, and accuracy of 90.2%, 97.2%, and 92.5%, respectively for the detection of the presence of an AVS, with near perfect interrater agreement (κ=0.963 [95% CI, 0.912-1.0]). The performance of ASL alone was higher than that of other magnetic resonance imaging sequences, individually or combined, and higher than that of computed tomography angiography. CONCLUSIONS ASL has strong diagnostic performance for the detection of AVS in the initial workup of intracerebral hemorrhage in children. If our findings are confirmed in other settings, ASL may be a helpful diagnostic imaging modality for patients with pediatric nontraumatic intracerebral hemorrhage. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: 3618210420, 2217698.
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Affiliation(s)
- Jean François Hak
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Université de Paris, INSERM UMR 1266 IMA-BRAIN, Department of Interventional Neuroradiology, GHU Paris, France (J.F.H., G.B., B.K., O.N.)
| | - Grégoire Boulouis
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Université de Paris, INSERM UMR 1266 IMA-BRAIN, Department of Interventional Neuroradiology, GHU Paris, France (J.F.H., G.B., B.K., O.N.)
| | - Basile Kerleroux
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Université de Paris, INSERM UMR 1266 IMA-BRAIN, Department of Interventional Neuroradiology, GHU Paris, France (J.F.H., G.B., B.K., O.N.)
| | - Sandro Benichi
- The Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163 (S.B., S.S., T.B.), University hospital Necker-Enfants-malades, Paris, France
| | - Sarah Stricker
- The Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163 (S.B., S.S., T.B.), University hospital Necker-Enfants-malades, Paris, France
| | - Florent Gariel
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Department of Neuroradiology, University Hospital of Bordeaux, France (F.G.)
| | - Lorenzo Garzelli
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France
| | - Philippe Meyer
- Pediatric Neuro ICU (P.M.), University hospital Necker-Enfants-malades, Paris, France
| | - Manoelle Kossorotoff
- French Center for Pediatric Stroke, INSERM U894 (M.K., T.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Department of Pediatric Neurology (M.K.), AP-HP, University hospital Necker-Enfants-malades, Paris, France
| | - Nathalie Boddaert
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France
| | - Vincent Vidal
- Department of Radiology (V.V.), University Hospital La Timone Hospital, AP-HM, Marseille, France
| | - Nadine Girard
- the Department of Neuroradiology (N.G.), University Hospital La Timone Hospital, AP-HM, Marseille, France
| | - Volodia Dangouloff Ros
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France
| | - Francis Brunelle
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France
| | - Thomas Blauwblomme
- The Department of Pediatric Neurosurgery, Institut Imagine, INSERM UMR 1163 (S.B., S.S., T.B.), University hospital Necker-Enfants-malades, Paris, France.,French Center for Pediatric Stroke, INSERM U894 (M.K., T.B., O.N.), University hospital Necker-Enfants-malades, Paris, France
| | - Olivier Naggara
- Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,French Center for Pediatric Stroke, INSERM U894 (M.K., T.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.,Université de Paris, INSERM UMR 1266 IMA-BRAIN, Department of Interventional Neuroradiology, GHU Paris, France (J.F.H., G.B., B.K., O.N.)
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24
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Parenrengi MA, Suryaningtyas W, Fauza J. Endovascular embolization for cases of 'hidden' pediatric cerebral arteriovenous malformations: A diagnostic & therapeutic challenge. Int J Surg Case Rep 2021; 86:106347. [PMID: 34481131 PMCID: PMC8416958 DOI: 10.1016/j.ijscr.2021.106347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/22/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ruptured arteriovenous malformations (AVM) hold a larger proportion as the cause of spontaneous intracranial hemorrhage in children compared to those in adults. Although surgical excision still remains as the gold standard therapy for arteriovenous malformations, some smaller ones are reported to resolve from embolization alone. However, difficulty arises when small arteriovenous malformations are not detected on certain diagnostic modalities such as Computed Tomography Angiography (CTA), giving rise to false negatives, which may compromise appropriate management of patients. Endovascular embolization can be used as alternative options as diagnostic and therapy for invisible arteriovenous malformation in children. We report two cases of ruptured paediatrics arteriovenous malformations with a complication of hydrocephalus, managed with endovascular embolization and a cerebrospinal fluid diversionary procedure. CASE DESCRIPTION We report 2 case in from Dr. Soetomo academic general hospital in 2021, the first case was a fully conscious 6-year-old-female child with sudden left-sided weakness and severe headache in January, and the second case a 9-year-old female came with decreased consciousness in May. Both had evidence of intracerebral hemorrhage, intraventricular hemorrhage, and hydrocephalus on head radiological examination, but no visible vascular malformations on Computed Tomography Angiography. The first patient was treated with extra ventricular drainage initially, while the second case was not. Transfemoral cerebral angiography revealed small arteriovenous malformations in both patients, and both had successful endovascular embolization afterwards. The first case was shunt-free, while the second case had her drainage switched to ventriculoperitoneal shunt right after the embolization procedure. Both patients recovered fully without complications and sequelae, and were discharged afterwards. DISCUSSION Both patients did not undergo surgical resection of the arteriovenous malformations; the first case only underwent endovascular embolization, while the second case underwent embolization and ventriculoperitoneal shunting. The cases described here help highlight the irreplaceable role of Transfemoral Cerebral Angiography as a gold standard for cases for arteriovenous malformations compared to other modalities, such as Computed Tomography Angiography (CTA). Smaller arteriovenous malformations in paediatrics are reported to achieve complete radiological resolution, and cerebrospinal fluid diversion in hydrocephalic cases are not always performed. Several factors to be considered include initial consciousness and severity of neurological deficit, which were taken into account in the management of our patients. CONCLUSION Embolization procedures may be beneficial in some pediatric arteriovenous malformations, preferably in smaller ones that undetectable by angiography. Several factors such as the consciousness and neurological deficit upon initial presentation may help in the decision making of these cases.
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Affiliation(s)
- Muhammad Arifin Parenrengi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
| | - Wihasto Suryaningtyas
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
| | - Joandre Fauza
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
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25
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Abstract
Intracranial vascular abnormalities rarely are encountered in primary care. Many of the pathologies are occult and prognosis varies widely between inconsequential variants of anatomy to acutely life-threatening conditions. Consequently, there often is a great deal of anxiety associated with any potential diagnosis. This article reviews anatomic intracranial vascular lesions, including vascular malformations (arteriovenous malformations/arteriovenous fistulae and cavernous malformations), structural arteriopathies (aneurysms and moyamoya), and common developmental anomalies of the vasculature. The focus includes a general overview of anatomy, pathology, epidemiology, and key aspects of evaluation for the primary care provider and a review of common questions encountered in practice.
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26
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Govindarajan V, Burks JD, Luther EM, Thompson JW, Starke RM. Medical Adjuvants in the Treatment of Surgically Refractory Arteriovenous Malformations of the Head and Face: Case Report and Review of Literature. Cerebrovasc Dis 2021; 50:493-499. [PMID: 34198289 DOI: 10.1159/000515168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) of the brain and face present unique challenges for clinicians. Cerebral AVMs may induce hemorrhage or form aneurysms, while facial AVMs can cause significant disfigurement and pain. Moreover, facial AVMs often draw blood supply from arteries providing critical blood flow to other important structures of the head which may make them impossible to treat curatively. Medical adjuvants may be an important consideration in the management of these patients. SUMMARY We conducted a systematic review of the literature to identify other instances of molecular target of rapamycin (mTOR) inhibitors used as medical adjuvants for the treatment of cranial and facial AVMs. We also present 2 cases from our own institution where patients were treated with partial embolization, followed by adjuvant therapy with rapamycin. After screening a total of 75 articles, 7 were identified which described use of rapamycin in the treatment of inoperable cranial or facial AVM. In total, 21 cases were reviewed. The median treatment duration was 12 months (3-24.5 months), and the highest recorded dose was 3.5 mg/m2. 76.2% of patients demonstrated at least a partial response to rapamycin therapy. In 2 patients treated at our institution, symptomatic and radiographic improvement were noted 6 months after initiation of therapy. Key Messages: Early results have been encouraging in a small number of patients with inoperable AVM of the head and face treated with mTOR inhibitors. Further study of medical adjuvants such as rapamycin may be worthwhile.
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Affiliation(s)
- Vaidya Govindarajan
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua D Burks
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan M Luther
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John W Thompson
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
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27
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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Stricker S, Boulouis G, Benichi S, Bourgeois M, Gariel F, Garzelli L, Hak JF, Alias Q, Kerleroux B, Beccaria K, Chivet A, de Saint Denis T, James S, Paternoster G, Zerah M, Kossorotoff M, Boddaert N, Brunelle F, Meyer P, Puget S, Naggara O, Blauwblomme T. Acute surgical management of children with ruptured brain arteriovenous malformation. J Neurosurg Pediatr 2021; 27:437-445. [PMID: 33482644 DOI: 10.3171/2020.8.peds20479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM. METHODS This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury. RESULTS A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently. CONCLUSIONS HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.
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Affiliation(s)
| | - Grégoire Boulouis
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Florent Gariel
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Lorenzo Garzelli
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Basile Kerleroux
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | | | | | | | | | | | - Nathalie Boddaert
- 1APHP, Necker Hospital
- 2Université de Paris
- 4INSERM U1163, Imagine Institute, Paris, France
| | | | | | | | - Olivier Naggara
- 1APHP, Necker Hospital
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Thomas Blauwblomme
- 1APHP, Necker Hospital
- 2Université de Paris
- 4INSERM U1163, Imagine Institute, Paris, France
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29
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Steinberg JA, Brandel MG, Kang KM, Rennert RC, Pannell JS, Olson SE, Gonda DD, Khalessi AA, Levy ML. Arteriovenous malformation surgery in children: the Rady Children's Hospital experience (2002-2019). Childs Nerv Syst 2021; 37:1267-1277. [PMID: 33404725 DOI: 10.1007/s00381-020-04994-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Compared to adult AVMs, there is a paucity of data on the microsurgical treatment of pediatric AVMs. We report our institutional experience with pediatric AVMs treated by microsurgical resection with or without endovascular embolization and radiation therapy. METHODS We retrospectively reviewed all patients ≤ 18 years of age with cerebral AVMs that underwent microsurgical resection at Rady Children's Hospital 2002-2019. RESULTS Eighty-nine patients met inclusion criteria. The mean age was 10.3 ± 5.0 years, and 56% of patients were male. In total, 72 (81%) patients presented with rupture. Patients with unruptured AVMs presented with headache (n = 5, 29.4%), seizure (n = 9, 52.9%), or incidental finding (n = 3, 17.7%). The mean presenting mRS was 2.8 ± 1.8. AVM location was lobar in 78%, cerebellar/brainstem in 15%, and deep supratentorial in 8%. Spetzler-Martin grade was I in 28%, II in 45%, III in 20%, IV in 6%, and V in 1%. Preoperative embolization was utilized in 38% of patients and more frequently in unruptured than ruptured AVMs (62% vs. 32%, p = 0.022). Radiographic obliteration was achieved in 76/89 (85.4%) patients. Complications occurred in 7 (8%) patients. Annualized rates of delayed rebleeding and recurrence were 1.2% and 0.9%, respectively. The mean follow-up was 2.8 ± 3.1 years. A good neurological outcome (mRS score ≤ 2) was obtained in 80.9% of patients at last follow-up and was improved relative to presentation for 75% of patients. CONCLUSIONS Our case series demonstrates high rates of radiographic obliteration and relatively low incidence of neurologic complications of treatment or AVM recurrence.
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Affiliation(s)
- Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - David D Gonda
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA. .,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
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30
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Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study. CHILDREN-BASEL 2021; 8:children8030215. [PMID: 33799749 PMCID: PMC7998913 DOI: 10.3390/children8030215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
Abstract
Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.
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31
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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32
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Mueller O, Kasper E, Droege F, Goericke S, Stein KP, Sure U. Cerebral Arteriovenous Malformations in Pediatric Patients with Hereditary Hemorrhagic Telangiectasia: Re-evaluating Appearance, Bleeding Risk, and Treatment Necessity in a Selective Meta-analysis. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1715499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractPediatric patients suffering from cerebral nidal arteriovenous malformations are a unique population due to the rare occurrence of the disease. Diagnosis of hereditary hemorrhagic telangiectasia (HHT) in children is a rare event and mainly restricted to coincidental detection from screening of possibly afflicted family members. In patients with HHT, it is well known that the incidence of cerebral vascular malformations (CVMs) is higher than expected when compared with the nonafflicted population. Even though CVMs comprise a variety of different distinct anatomical and radiographic entities (e.g., capillary telangiectasia, nidal arteriovenous malformation [AVM], cavernous malformation, dural or pial as well as mixed fistula, and vein of Galen malformation), they are mostly summarized and analyzed all in one category due to the low number of individual cases identified in single centers. Nevertheless, the best treatment algorithm will likely vary significantly between different CVMs as does the clinical presentation and the natural course of the CVM. It is therefore the objective of this article to focus on nidal AVMs in pediatric patients suffering from HHT. To this end, we performed a systematic selective literature research to estimate incidence, clinical and radiological appearance, as well as classification according to established grading system, and to evaluate the necessity of treatment of these lesions in light of their respective outcomes. Our line of arguments explains why we recommend to follow these lesions expectantly and suggest to keep pediatric patients under surveillance with sequential scans until they reach adulthood.
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Affiliation(s)
- Oliver Mueller
- Department of Neurosurgery, University of Essen, Essen, Germany
- Department of Neurosurgery, Dortmund Hospital, Dortmund, Germany
| | - Ekkehard Kasper
- Division of Neurosurgery, Hamilton General Hospital, Hamilton, Canada
| | - Freya Droege
- Department of Oto-Rhino-Laryngology, University of Essen, Essen, Germany
| | - Sophia Goericke
- Institute of Radiology, Neuroradiology and Interventional Radiology, University of Essen, Essen, Germany
| | - Klaus-Peter Stein
- Department of Neurosurgery, University of Essen, Essen, Germany
- Department of Neurosurgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University of Essen, Essen, Germany
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33
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Garzelli L, Shotar E, Blauwblomme T, Sourour N, Alias Q, Stricker S, Mathon B, Kossorotoff M, Gariel F, Boddaert N, Brunelle F, Meyer P, Naggara O, Clarençon F, Boulouis G. Risk Factors for Early Brain AVM Rupture: Cohort Study of Pediatric and Adult Patients. AJNR Am J Neuroradiol 2020; 41:2358-2363. [PMID: 33122204 DOI: 10.3174/ajnr.a6824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Whether architectural characteristics of ruptured brain AVMs vary across the life span is unknown. We aimed to identify angioarchitectural features associated with brain AVMs ruptured early in life. MATERIALS AND METHODS Patients with ruptured brain AVMs referred to 2 distinct academic centers between 2000 and 2018 were pooled and retrospectively analyzed. Imaging was retrospectively reviewed for angioarchitectural characteristics, including nidus size, location, Spetzler-Martin grade, venous drainage, and arterial or nidal aneurysm. Angioarchitecture variations across age groups were analyzed using uni- and multivariable models; then cohorts were pooled and analyzed using Kaplan-Meier and Cox models to determine factors associated with earlier rupture. RESULTS Among 320 included patients, 122 children (mean age, 9.8 ± 3.8 years) and 198 adults (mean age, 43.3 ± 15.7 years) were analyzed. Pediatric brain AVMs were more frequently deeply located (56.3% versus 21.2%, P < .001), with a larger nidus (24.2 versus 18.9 mm, P = .002), were less frequently nidal (15.9% versus 23.5%, P = .03) and arterial aneurysms (2.7% versus 17.9%, P < .001), and had similar drainage patterns or Spetzler-Martin grades. In the fully adjusted Cox model, supratentorial, deep brain AVM locations (adjusted relative risk, 1.19; 95% CI, 1.01-1.41; P = .03 and adjusted relative risk, 1.43; 95% CI, 1.22-1.67; P < .001, respectively) and exclusively deep venous drainage (adjusted relative risk, 1.46, 95% CI, 1.21-1.76; P < .001) were associated with earlier rupture, whereas arterial or nidal aneurysms were associated with rupture later in life. CONCLUSIONS The angioarchitecture of ruptured brain AVMs significantly varies across the life span. These distinct features may help to guide treatment decisions for patients with unruptured AVMs.
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Affiliation(s)
- L Garzelli
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Departments of Neuroradiology (L.G., F.C.)
| | - E Shotar
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - T Blauwblomme
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke.,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - N Sourour
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - Q Alias
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.)
| | - S Stricker
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke
| | - B Mathon
- Neurosurgery (B.M.), Sorbonne University, Paris, France.,Neurosurgery (B.M.), Pitié-Salpêtrière University Hospital, Public Assistance-Paris Hospitals, Paris, France.,Brain and Spine Institute (B.M.), Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1127; Centre National de la Recherche Scientifique, Unité Mixte de Recherche 7225, Paris, France
| | - M Kossorotoff
- Department of Pediatric Neurology (M.K.), French Center for Pediatric Stroke
| | - F Gariel
- Department of Neuroimaging (F.G.), Pellegrin Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - N Boddaert
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Brunelle
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - P Meyer
- Department of Anesthesiology (P.M.), Necker-Enfants Malades University Hospital, Public Assistance-Paris Hospitals, Paris, France
| | - O Naggara
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Clarençon
- Departments of Neuroradiology (L.G., F.C.).,Department of Neuroradiology (E.S., N.S., F.C.)
| | - G Boulouis
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France .,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
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Lubicz B, Christiaens F. Endovascular treatment of intracranial vascular malformations in children. Dev Med Child Neurol 2020; 62:1124-1130. [PMID: 32533582 DOI: 10.1111/dmcn.14589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 11/26/2022]
Abstract
Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis.
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Affiliation(s)
- Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Florence Christiaens
- Department of Pediatric Neurology, Erasme University Hospital, Brussels, Belgium
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35
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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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36
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Natural history of high-grade pediatric arteriovenous malformations: implications for management options. Childs Nerv Syst 2020; 36:2055-2061. [PMID: 32166342 DOI: 10.1007/s00381-020-04550-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/18/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Cerebral arteriovenous malformations are a common cause of pediatric intracranial hemorrhage. Often, small, superficial, lesions are treated surgically; however, more complex, deeper, eloquently located lesions portend higher-risk features and suffer from limitations in treatment. We sought to examine our institution's experience with the natural history of these high-grade arteriovenous malformations to explore outcomes with conservative treatment. METHODS A retrospective chart review was performed to identify all pediatric cases of intracranial arteriovenous malformations seen at our institution from 2005 to 2018. Subjects with Spetzler-Martin grade IV or V lesions, treated conservatively, were examined for primary outcomes including rupture rate, progression, and functional outcomes. RESULTS A total of 14 patients were included in the study, of which, 78.57% were classified as Spetzler-Martin grade IV and 21.43% Spetzler-Martin grade V. All patients in this study were treated conservatively, with surveillance, followed for a mean of 32.17 months (range 9.43-79.10). 7.14% experienced delayed hemorrhage or re-rupture, 7.14% had hydrocephalus, and 14.29% had seizures. Neurological sequelae included weakness, visual impairment, speech impairment, sensory changes, and dystonia; functionally independent outcomes, defined as modified Rankin Score of 0-2, were seen in 85.71% of patients. CONCLUSION Our experience suggests that patients with large, deep lesions have significant morbidity with high rates of rupture and subsequent neurologic deficits. However, intervention of these lesions may carry high risk, and the literature suggests such lesions may have less favorable outcomes when treated. We propose conservative treatment for high-grade arteriovenous malformations as a viable option with good functional outcomes in a cohort often without good options for conventional treatment.
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37
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Stricker S, Boulouis G, Benichi S, Gariel F, Garzelli L, Beccaria K, Chivet A, de Saint Denis T, James S, Paternoster G, Zerah M, Bourgeois M, Boddaert N, Brunelle F, Meyer P, Puget S, Naggara O, Blauwblomme T. Hydrocephalus in children with ruptured cerebral arteriovenous malformation. J Neurosurg Pediatr 2020; 26:283-287. [PMID: 32442968 DOI: 10.3171/2020.3.peds19680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is a strong determinant of poor neurological outcome after intracerebral hemorrhage (ICH). In children, ruptured brain arteriovenous malformations (bAVMs) are the dominant cause of ICH. In a large prospective cohort of pediatric patients with ruptured bAVMs, the authors analyzed the rates and predictive factors of hydrocephalus requiring acute external ventricular drainage (EVD) or ventriculoperitoneal shunt (VPS). METHODS The authors performed a single-center retrospective analysis of the data from a prospectively maintained database of children admitted for a ruptured bAVM since 2002. Admission clinical and imaging predictors of EVD and VPS placement were analyzed using univariate and multivariate statistical models. RESULTS Among 114 patients (mean age 9.8 years) with 125 distinct ICHs due to ruptured bAVM, EVD and VPS were placed for 55/125 (44%) hemorrhagic events and 5/114 patients (4.4%), respectively. A multivariate nominal logistic regression model identified low initial Glasgow Coma Scale (iGCS) score, hydrocephalus on initial CT scan, the presence of intraventicular hemorrhage (IVH), and higher modified Graeb Scale (mGS) score as strongly associated with subsequent need for EVD (all p < 0.001). All children who needed a VPS had initial hydrocephalus requiring EVD and tended to have higher mGS scores. CONCLUSIONS In a large cohort of pediatric patients with ruptured bAVM, almost half of the patients required EVD and 4.4% required permanent VPS. Use of a low iGCS score and a semiquantitative mGS score as indicators of the IVH burden may be helpful for decision making in the emergency setting and thus improve treatment.
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Affiliation(s)
| | - Grégoire Boulouis
- 1APHP, Necker Hospital, Université de Paris
- 2Department of Neuroradiology, INSERM U1266
- 4Interventional Neuroradiology Centre Hospitalier Sainte-Anne, Paris, France
| | | | | | | | - Kevin Beccaria
- 1APHP, Necker Hospital, Université de Paris
- 3Imagine Institute, INSERM U1163; and
| | | | | | | | | | - Michel Zerah
- 1APHP, Necker Hospital, Université de Paris
- 2Department of Neuroradiology, INSERM U1266
| | | | - Nathalie Boddaert
- 1APHP, Necker Hospital, Université de Paris
- 3Imagine Institute, INSERM U1163; and
| | | | | | - Stephanie Puget
- 1APHP, Necker Hospital, Université de Paris
- 3Imagine Institute, INSERM U1163; and
| | - Olivier Naggara
- 1APHP, Necker Hospital, Université de Paris
- 2Department of Neuroradiology, INSERM U1266
- 4Interventional Neuroradiology Centre Hospitalier Sainte-Anne, Paris, France
| | - Thomas Blauwblomme
- 1APHP, Necker Hospital, Université de Paris
- 3Imagine Institute, INSERM U1163; and
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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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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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Robertson RL, Palasis S, Rivkin MJ, Pruthi S, Bartel TB, Desai NK, Kadom N, Kulkarni AV, Lam HFS, Maheshwari M, Milla SS, Mirsky DM, Myseros JS, Partap S, Radhakrishnan R, Soares BP, Trout AT, Udayasankar UK, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Cerebrovascular Disease-Child. J Am Coll Radiol 2020; 17:S36-S54. [PMID: 32370977 DOI: 10.1016/j.jacr.2020.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 10/24/2022]
Abstract
Stroke is an uncommon but an important and under-recognized cause of morbidity and mortality in children. Strokes may be due to either brain ischemia or intracranial hemorrhage. Common symptoms of pediatric acute stroke include headache, vomiting, focal weakness, numbness, visual disturbance, seizures, and altered consciousness. Most children presenting with an acute neurologic deficit do not have an acute stroke, but have symptoms due to stroke mimics which include complicated migraine, seizures with postictal paralysis, and Bell palsy. Because of frequency of stroke mimics, in children and the common lack of specificity in symptoms, the diagnosis of a true stroke may be delayed. There are a relatively large number of potential causes of stroke mimic and true stroke. Consequently, imaging plays a critical role in the assessment of children with possible stroke and especially in children who present with acute onset of stroke symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Susan Palasis
- Panel Chair, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael J Rivkin
- Boston Children's Hospital, Boston, Massachusetts; American Academy of Neurology
| | - Sumit Pruthi
- Panel Vice Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | - Nadja Kadom
- Emory University and Children's of Atlanta (Egleston), Atlanta, Georgia
| | - Abhaya V Kulkarni
- Hospital for Sick Children, Toronto, Ontario, Canada; Neurosurgery expert
| | - H F Samuel Lam
- Sutter Medical Center, Sacramento, California; American College of Emergency Physicians
| | | | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery expert
| | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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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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Huang X, Cheng Z, Xu Y, Xia L, Zhan Z, Xu T, Cao Y, Han Z. Associations of Clinical Characteristics and Etiology With Death in Hospitalized Chinese Children After Spontaneous Intracerebral Hemorrhage: A Single-Center, Retrospective Cohort Study. Front Pediatr 2020; 8:576077. [PMID: 33614538 PMCID: PMC7890113 DOI: 10.3389/fped.2020.576077] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023] Open
Abstract
Objective: We retrospectively analyzed clinical characteristics, etiology, and mortality risk factors in pediatric cases of non-traumatic spontaneous intracerebral hemorrhage. Methods: This study involved children between 29 days and 18 years old with confirmed spontaneous intracerebral hemorrhage based on head CT or MRI at the Second Affiliated Hospital of Wenzhou Medical University and Yuying Children's Hospital from January 2008 to March 2020. Demographic and clinical characteristics, etiology, imaging, and treatment data were collected at baseline. Potential risk factors of in-hospital death were identified using univariate analysis and multivariate logistic regression. Result: A total of 200 children (126 males, median age 5 years) were included in the study. Clinical symptoms of spontaneous intracerebral hemorrhage were typically non-specific (79.5%). One third of patients (31.1%) had a Glasgow Coma Scale score (GCS) ≤ 8, and nearly two-thirds (60.5%) showed a combination of ventricular hemorrhage or subarachnoid hemorrhage. Supratentorial hemorrhage was more common. Cerebrovascular disease (37.0%) and hematological disease (33.5%) were the most frequent etiologies of spontaneous intracerebral hemorrhage. Most patients (74.5%) received non-surgical treatment, while 25.5% received surgical treatment. After an average of 12 days of treatment, 167 children (83.5%) survived and 33 (16.5%) died. Multivariate logistic regression showed herniation syndrome, and low GCS (≤ 8) to be associated with increased risk of mortality, while hemorrhage due to arteriovenous malformation was associated with lower risk of mortality. Conclusion: Our data suggest that cerebrovascular disease is the most common cause of spontaneous intracerebral hemorrhage among children, and that arteriovenous malformation is associated with lower risk of death in hospital. Conversely, the presence of herniation syndrome, low GCS (≤ 8) increase risk of in-hospital mortality. Our results underscore the importance of timely imaging and supplementary examinations in cases of suspected spontaneous intracerebral hemorrhage.
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Affiliation(s)
- Xiaoyan Huang
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zicheng Cheng
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lingfan Xia
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenxiang Zhan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tong Xu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yungang Cao
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Chen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, Sheehan JP. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery 2020; 84:696-708. [PMID: 29762746 DOI: 10.1093/neuros/nyy174] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 04/05/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microsurgery (MS) and stereotactic radiosurgery (SRS) remain the preferred interventions for the curative treatment of brain arteriovenous malformations (AVM), but their relative efficacy remains incompletely defined. OBJECTIVE To compare the outcomes of MS to SRS for AVMs through a retrospective, matched cohort study. METHODS We evaluated institutional databases of AVM patients who underwent MS and SRS. MS-treated patients were matched, in a 1:1 ratio based on patient and AVM characteristics, to SRS-treated patients. Statistical analyses were performed to compare outcomes data between the 2 cohorts. The primary outcome was defined as AVM obliteration without a new permanent neurological deficit. RESULTS The matched MS and SRS cohorts were each comprised of 59 patients. Both radiological (85 vs 11 mo; P < .001) and clinical (92 vs 12 mo; P < .001) follow-up were significantly longer for the SRS cohort. The primary outcome was achieved in 69% of each cohort. The MS cohort had a significantly higher obliteration rate (98% vs 72%; P = .001), but also had a significantly higher rate of new permanent deficit (31% vs 10%; P = .011). The posttreatment hemorrhage rate was significantly higher for the SRS cohort (10% for SRS vs 0% for MS; P = .027). In subgroup analyses of ruptured and unruptured AVMs, no significant differences between the primary outcomes were observed. CONCLUSION For patients with comparable AVMs, MS and SRS afford similar rates of deficit-free obliteration. Nidal obliteration is more frequently achieved with MS, but this intervention also incurs a greater risk of new permanent neurological deficit.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tony R Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - M Yashar Kalani
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Alias Q, Boulouis G, Blauwblomme T, Benichi S, Beccaria K, Gariel F, Garzelli L, Meyer P, Kossorotoff M, Boddaert N, Brunelle F, Naggara O. First Line Onyx Embolization in Ruptured Pediatric Arteriovenous Malformations : Safety and Efficacy. Clin Neuroradiol 2019; 31:155-163. [PMID: 31802150 DOI: 10.1007/s00062-019-00861-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/18/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Brain arteriovenous malformations (bAVM) are the main cause of pediatric intracerebral hemorrhage (pICH). Embolization with Onyx (ev3, Irvine, CA, USA) in children with ruptured bAVM has been infrequently reported. The aim of this study was to assess the safety and efficacy profile of Onyx embolization as first line endovascular treatment of ruptured pediatric bAVMs. METHODS Children with non-traumatic pICH due to bAVM rupture at a pediatric quaternary care center were prospectively enrolled in a registry and retrospectively analyzed between 2013 and 2018. Clinical and demographic data, treatment modalities and clinical imaging follow-up were retrieved, and detailed procedural data were retrospectively assessed by two investigators. The safety (procedural morbidity and mortality) and efficacy (obliteration and interval rebleeding) were evaluated. RESULTS In this study 29 children treated for a bAVM by Onyx embolization were included (14 girls, 48%; median age 11.1 years, interquartile range, IQR 8.1-12.7 years) with a total of 72 endovascular sessions (median of 2 sessions per patient IQR 1-3). The AVMs were deeply located in 23 patients (79%). No systemic complications occurred, and no child experienced embolization-related persistent neurological deficits. Non-clinically relevant complications were observed during five procedures, unrelated to Onyx. After a mean follow-up of 31 months from rupture complete obliteration rates were 100%, 89%, 29%, 14% in bAVM Spetzler Martin grades I, II, III and IV-V, respectively. CONCLUSION It was found that Onyx embolization is safe and represents a good option for an initial treatment approach, in a sequential treatment strategy for pediatric ruptured brain AVMs. Younger age may not be an argument to deny Onyx embolization.
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Affiliation(s)
- Quentin Alias
- Pediatric Radiology, Necker Children Hospital, Paris, France
| | - Grégoire Boulouis
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Kevin Beccaria
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Florent Gariel
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.,Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France.,Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | | | - Philippe Meyer
- Pediatric Neuro ICU, Necker Children Hospital, APHP, Paris, France
| | - Manoelle Kossorotoff
- Department of Pediatric Neurology, French Centre for Pediatric Stroke, APHP University Necker Children Hospital, Paris, France
| | | | | | - Olivier Naggara
- Pediatric Radiology, Necker Children Hospital, Paris, France. .,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.
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Boulouis G, Blauwblomme T, Hak JF, Benichi S, Kirton A, Meyer P, Chevignard M, Tournier-Lasserve E, Mackay MT, Chabrier S, Cordonnier C, Kossorotoff M, Naggara O. Nontraumatic Pediatric Intracerebral Hemorrhage. Stroke 2019; 50:3654-3661. [DOI: 10.1161/strokeaha.119.025783] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Gregoire Boulouis
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Jean François Hak
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
- Neuroimaging Department, CHRU La Timone, Marseille, France (J.F.H.)
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, AB, Canada (A.K.)
- Pediatric Neuro ICU (A.K.)
| | | | - Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint-Maurice Hospitals (M.C.)
| | - Elisabeth Tournier-Lasserve
- Genetics of Neurovascular disorders, AP-HP, Hôpital Lariboisière and Université de Paris, NeuroDiderot, Inserm, F-75010 (E.T.-L.)
| | - Mark T. Mackay
- Neurology Department, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, and Department of Paediatrics, University of Melbourne, Australia (M.T.M.)
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Center for Pediatic Stroke, F-42055 Saint-Étienne, France (S.C.)
| | - Charlotte Cordonnier
- Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Neurology Department, France (C.C.)
| | - Manoëlle Kossorotoff
- Department of Pediatric Neurology, French Center for Pediatic Stroke, NEM (M.K.)
| | - Olivier Naggara
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
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Maynard K, LoPresti M, Iacobas I, Kan P, Lam S. Antiangiogenic agent as a novel treatment for pediatric intracranial arteriovenous malformations: case report. J Neurosurg Pediatr 2019; 24:673-679. [PMID: 31585413 DOI: 10.3171/2019.7.peds1976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/16/2019] [Indexed: 11/06/2022]
Abstract
Intracerebral arteriovenous malformations (AVMs) are high-flow collections of abnormal vessels and a common cause of pediatric intracranial hemorrhage. There are few treatment options available for AVMs not amenable to surgical resection, endovascular embolization, radiosurgery, or multimodality treatment. The authors sought to review the molecular and genetic pathways that have been implicated in the formation of AVMs, focusing on the possibility of medically targeting these pathways in the treatment of AVMs. In the novel case presented here, a pediatric patient who was diagnosed with an intracranial AVM unamenable to conventional treatments underwent alternative treatment with molecular pathway inhibitors.
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Affiliation(s)
- Ken Maynard
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | - Melissa LoPresti
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Ionela Iacobas
- 4Division of Hematology/Oncology, Department of Pediatrics, and
- 5Vascular Anomalies Center, Texas Children's Hospital, Houston; and
- 6Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Sandi Lam
- 1Pediatric Neurosurgery, Texas Children's Hospital, Houston
- 2Department of Neurosurgery, Baylor College of Medicine, Houston
- 3Department of Neurosurgery, University of Texas Medical Branch, Galveston
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Schunemann V, Wang JL, Dornbos D, Youssef PP, Sribnick E, Leonard J, Nimjee SM. One and Done: Multimodal Treatment of Pediatric Cerebral Arteriovenous Malformations in a Single Anesthesia Event. World Neurosurg 2019; 130:e715-e721. [DOI: 10.1016/j.wneu.2019.06.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
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48
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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Ravindra VM, Bollo RJ, Eli IM, Griauzde J, Lanpher A, Klein J, Zhu H, Brockmeyer DL, Kestle JRW, Couldwell WT, Scott RM, Smith E. A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 30952115 DOI: 10.3171/2019.2.peds18731] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits. METHODS The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living. RESULTS Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up. CONCLUSIONS Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.
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Affiliation(s)
- Vijay M Ravindra
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Robert J Bollo
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ilyas M Eli
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Julius Griauzde
- 2Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Arianna Lanpher
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Jennifer Klein
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Huirong Zhu
- 4Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Douglas L Brockmeyer
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - John R W Kestle
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - R Michael Scott
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Edward Smith
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
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Jhaveri A, Amirabadi A, Dirks P, Kulkarni AV, Shroff MM, Shkumat N, Krings T, Pereira VM, Rea V, Muthusami P. Predictive Value of MRI in Diagnosing Brain AVM Recurrence after Angiographically Documented Exclusion in Children. AJNR Am J Neuroradiol 2019; 40:1227-1235. [PMID: 31248861 DOI: 10.3174/ajnr.a6093] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE MRI is routinely performed following brain AVM after treatment in children. Our aim was to determine the predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence in children, compared with conventional angiography and the role of 3D rotational angiography-MR imaging fusion in these cases. MATERIALS AND METHODS We included all pediatric patients with brain AVMs during an 18-year period with angiographically documented obliteration after treatment. Patients underwent 3T MR imaging, including contrast-enhanced MR imaging, TOF-MRA, and conventional angiography, with a subset undergoing 3D rotational angiography. The predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence were determined. CTA sections reconstructed from 3D rotational angiography were coregistered with and fused to 3D-T1WI for analysis. RESULTS Thirty-nine children (10.8 ± 3.9 years of age; range, 2-17 years; male/female ratio, 19:20; mean Spetzler-Martin grade, 1.9 ± 0.6) met the inclusion criteria. Of these, 13 had angiographically confirmed brain AVM recurrence, 8 following surgery and 5 following embolization. Sensitivity, specificity, and positive and negative predictive values for recurrence were the following: contrast-enhanced MR imaging: 84.6%, 38.5%, 40.7%, 81.8%; TOF-MRA: 50.0%, 96.1%, 85.7%, 79.3%; both: 75.0%, 90.9%, 85.7%, 83.3%. 3D rotational angiography-MR imaging fused images confirmed or excluded recurrence in all available cases (13/13). Embolization-only treatment was a significant predictor of recurrence (OR = 32.4, P = .006). MR imaging features predictive of recurrence included a tuft of vessels on TOF-MRA and nodular juxtamural/linear enhancement with a draining vein on contrast-enhanced MR imaging. CONCLUSIONS MR imaging is useful for surveillance after brain AVM treatment in children, but conventional angiography is required for definitive diagnosis of recurrence. TOF-MRA and contrast-enhanced MR imaging provide complementary information for determining brain AVM recurrence and should be interpreted in conjunction. 3D rotational angiography-MR imaging fusion increases the diagnostic confidence regarding brain AVM recurrence and is therefore suited for intraoperative neuronavigation.
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Affiliation(s)
- A Jhaveri
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - A Amirabadi
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Dirks
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - A V Kulkarni
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M M Shroff
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - N Shkumat
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - T Krings
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V Rea
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Muthusami
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
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