Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey

Lesion-Filling Index from Quantitative DSA Correlates with Hemorrhage of Cerebral AVM

BACKGROUND AND PURPOSE

Rupture is the most life-threatening manifestation of cerebral AVMs. This study aimed to explore the hemodynamic mechanism of AVM rupture. We introduced a new quantitative DSA parameter that can reflect the degree of intranidal blood stasis, called the lesion-filling index.

MATERIALS AND METHODS

This study examined patients with AVMs who had undergone both DSA and MR imaging between 2013 and 2014. Clinical presentations, angioarchitecture, and hemodynamic parameters generated from quantitative DSA were analyzed using univariate and multivariable logistic regression. The lesion-filling index was defined as the arterial diagnostic window divided by the volume of the AVM. To assess the correlation between the lesion-filling index and rupture, we incorporated the lesion-filling index into 2 published prediction models widely recognized for predicting AVM rupture risk, R2eD and VALE. The DeLong test was used to examine whether the addition of the lesion-filling index improved predictive efficacy.

RESULTS

A total of 180 patients with AVMs were included. The mean lesion-filling index values in the ruptured group were higher compared with the unruptured group (390.27 [SD, 919.81] versus 49.40 [SD, 98.25]), P < .001). A higher lesion-filling index was significantly correlated with AVM rupture in 3 different multivariable logistic models, adjusting for angioarchitecture factors (OR = 1.004, P = .02); hemodynamic factors (OR = 1.005, P = .009); and combined factors (OR = 1.004, P = .03). Both R2eD (area under the curve, 0.601 versus 0.624; P = .15) and VALE (area under the curve, 0.603 versus 0.706; P < .001) predictive models showed improved predictive performance after incorporating the lesion-filling index and conducting 10-fold cross-validation.

CONCLUSIONS

The lesion-filling index showed a strong correlation with AVM rupture, suggesting that overperfusion is the hemodynamic mechanism leading to AVM rupture.

Association of nidus size and rupture in brain arteriovenous malformations: Insight from angioarchitecture and hemodynamics

This study aims to investigate the correlation between AVM size and rupture by examining natural history, angioarchitecture characteristics, and quantitative hemodynamics. A retrospective review of 90 consecutive AVMs from the MATCH registry was conducted. Patients were categorized into small nidus (< 3 cm) and large nidus (≥ 3 cm) groups based on the Spetzler-Martin grading system. Natural history analysis used prospective cohort survival data, while imaging analysis examined angioarchitecture characteristics and quantitative hemodynamic parameters measured with QDSA. The small-nidus group had a significantly higher annualized rupture risk (2.3% vs. 1.0%; p = 0.011). Cross-sectional imaging revealed independent hemorrhagic risk factors, including small nidus (OR, 4.801; 95%CI, 1.280-18.008; p = 0.020) and draining vein stenosis (OR, 6.773; 95%CI, 1.179-38.911; p = 0.032). Hemodynamic analysis identified higher stasis index in the feeding artery (OR, 2.442; 95%CI, 1.074-5.550; p = 0.033), higher stasis index in the draining vein (OR, 11.812; 95%CI, 1.907-73.170; p = 0.008), and lower outflow gradient in the draining vein (OR, 1.658; 95%CI, 1.068-2.574; p = 0.024) as independent predictors of AVM rupture. The small nidus group also showed a higher likelihood of being associated with hemorrhagic risk factors. Small AVM nidus has a higher risk of rupture based on natural history, angioarchitecture, and hemodynamics. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT04572568.

Multimodality treatment for brain arteriovenous malformation in Mainland China: design, rationale, and baseline patient characteristics of a nationwide multicenter prospective registry

BACKGROUND

Brain arteriovenous malformation (AVM) is an important cause of hemorrhagic stroke in young adults, which can lead to severe neurological impairment. The registry of Multimodality treatment for brain ArTeriovenous malformation in mainland CHina (MATCH) is a national prospective registry to identify the natural history of AVMs in Asian population; to investigate traditional and emerging hemorrhagic predictors; and to explore the superiority of the multidisciplinary assessment in improving the long-term outcomes.  METHODS: Consecutive AVM patients will be enrolled from 52 participating hospitals in mainland China. Baseline demographic, clinical and imaging data will be collected prospectively. Conservation, microsurgery, embolization, stereotactic radiosurgery (SRS), and multimodal strategies are all included in this study. Patients will be divided into experimental and control group according to whether the treatment protocols are formulated by multidisciplinary team. Neurofunctional status, subsequent hemorrhage, seizure, and novel neurofunctional deficit will be queried at 3 months, annually (1 and 2 years), 3 years, and 10 years follow-up.

RESULTS

Between August 2011 and April 2021, 3241 AVMs were enrolled in 11 participating sites. Among them, 59.0% were male with an average age of 28.4 ± 14.6 years, 61.2% had rupture history and 2268 hemorrhagic events occurred before admission. The median Spetzler-Martin grade and Lawton-Young grade was 3 and 5, respectively. Microsurgery is the dominant strategy (35.7%), with a similar proportion of embolization, SRS, and a combination of both (12.7%; 14.8%; 11.8%; respectively). Among them, 15.43% underwent multidisciplinary assessment and received standardized treatment. At the most recent follow-up, 7.8% were lost and the median follow-up duration was 5.6 years.

CONCLUSIONS

The MATCH study is a large-sample nationwide prospective registry to investigate multimodality management strategy for AVMs. Data from this registry may also provide the opportunity for individualized risk assessment and the development of optimal individual management strategies.

TRIAL REGISTRATION

ClinicalTrials.gov Registry ( NCT04572568 ).

Pre-operative imaging and post-operative appearance of standard paediatric neurosurgical approaches: a training guide for neuroradiologists

A short-cut narrative review was conducted according to the SANRA guidelines to identify studies describing normal and abnormal postoperative radiological features of the most common paediatric neurosurgical procedures. Rather than focusing on the original pathology addressed by neurosurgical means, this review explored three main areas of operative neurosurgery: ventricular access, supratentorial & infratentorial craniotomies, and posterior fossa/craniocervical junction decompression. A total of twenty-three landmark papers were included for review based on their relevance to address the research question and serve as a practical guide for paediatric neuroradiology trainees and fellows. Accurate in text referencing of the ClinicalTrials.gov identifier, and weblink, has also been provided for all trials discussed in the results section. All the above is complemented by relevant iconography meant to describe a wide range of postoperative changes and early complications. Finally, the review is enriched by a discussion touching upon haemostatic agents, intentionally retained foreign bodies and the future of machine learning for neuroradiology reporting. Overall, the information presented in a systematic fashion will not only help trainees and fellows to deepen these topics and expand their knowledge in preparation for written and oral boards, but will also represent a useful resource for everyone including trained neuroradiologists and neurosurgeons themselves.