Hydrocephalus after arteriovenous malformation rupture

Pediatric Patients with Intracranial Arteriovenous Malformations: Trends in Emergency Room Presentation

BACKGROUND

Pediatric intracranial arteriovenous malformation (AVM) patients are commonly admitted to the emergency room (ER). Increasing patient utilization of the ER has been associated with healthcare disparities and a trend of decreased efficiency. The aim of this study was to evaluate the trends of pediatric AVM ER admissions over recent years and identify factors associated with health care resource utilization and outcomes.

METHODS

The 2016-2019 National Inpatient Sample was queried for patients under the age of 18 admitted with AVM. Cases of admission through the ER were identified. Demographic and severity factors associated with ER admission were explored using comparative and regression statistics.

RESULTS

Of 3875 pediatric patients with AVM admitted between 2016 and 2019, 1280 (33.0%) were admitted via the ER. Patients admitted via the ER were more likely to be in the lowest median income category (P < 0.001), on Medicaid insurance (P = 0.008), or in the South (P < 0.001) than patients admitted otherwise. There was increased severity and increased rates of intracranial hemorrhage (ICH) in patients admitted via the ER (P < 0.001). Finally, there were increasing trends in ER admissions and ICH throughout the years.

CONCLUSIONS

ER admission of pediatric AVM patients with ICH is increasing and is associated with a distinct socioeconomic profile and increased healthcare resource utilization. These findings may reflect decreased access to more advanced diagnostic modalities, primary care, and other important resources. Identifying populations with barriers to care is likely an important component of policy aimed at decreasing the risk of severe disease presentation.

An Unusual Cause of Neck Pain and Headache in Pregnancy

A previously healthy 21-year-old Caucasian female G1P0 at 32 weeks gestation presented to the ED for an episode of syncope. She also complained of headaches, neck pain, and blurry vision. Physical examination revealed a healthy pregnant female. Neurological examination demonstrated Grade III papilledema but was otherwise unremarkable. CT brain revealed hydrocephalus and intraventricular hemorrhage of unclear etiology MRI of the head was negative for a mass lesion. MRA/MRV of the head was negative, ruling out cavernous sinus thrombosis. Lumbar puncture was bloody but negative for infection. Infectious workup, including HSV, toxoplasmosis, and neurocysticercosis, was negative. An intraventricular drain was placed for hydrocephalus. While in the hospital, she developed sudden left-sided weakness, prompting an emergency C-section. Further workup with CT angio of the brain and neck revealed an arteriovenous malformation (AVM) involving the anterior spinal artery and adjacent venous plexus. Digital subtraction angiography showed a C2-3 pial AVM with a partially thrombosed nidal aneurysm. She was transferred to an outside hospital for embolization. Embolization obliterated the aneurysm, but residual flow remained in the AVM. Blood products are visible on sagittal MRI after embolization. At hospital discharge, her left-sided weakness had resolved, and her neurological examination was normal. The hydrocephalus had resolved.

Diffuse cerebral angiomatosis associated to basilar apex aneurysm

BACKGROUND

Diffuse cerebral angiomatosis (DCA) is a diffuse infiltration of normal brain by complex vascular structures. It differs from arteriovenous malformations (AVMs) that are composed of a nidus of vessels through which arteriovenous shunting occurs without interposed functional brain parenchyma. A rare subgroup of AVMs is diffuse with no recognizable nidus with functional neuronal tissue interspersed within the malformed vessels. We present a rare association of DCA and cerebral arterial aneurysm, which dramatically influenced the patient's prognosis.

CASE DESCRIPTION

A 43-year-old male patient with right hemispheric diffuse cerebral angiomatosis presented with a ruptured basilar tip aneurysm that was successfully embolised. Unfortunately, the patient developed a locked-in syndrome.

CONCLUSION

The present report shows a possible association between diffuse cerebral angiomatosis and cerebral aneurysms, but this association appears to be less strong than it is with other AVMs.

Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review

Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.

Development and validation of a model for predicting the risk of brain arteriovenous malformation rupture based on three-dimensional morphological features

Objective

Brain arteriovenous malformation (bAVM) is an important reason for intracranial hemorrhage. This study aimed at developing and validating a model for predicting bAVMs rupture by using three-dimensional (3D) morphological features extracted from Computed Tomography (CT) angiography.

Materials and methods

The prediction model was developed in a cohort consisting of 412 patients with bAVM between January 2010 and December 2020. All cases were partitioned into training and testing sets in the ratio of 7:3. Features were extracted from the 3D model built on CT angiography. Logistic regression was used to develop the model, with features selected using L1 Regularization, presented with a nomogram, and assessed with calibration curve, receiver operating characteristic (ROC) curve and decision curve analyze (DCA).

Results

Significant variations in associated aneurysm, deep located, number of draining veins, type of venous drainage, deep drainage, drainage vein entrance diameter (Dv), type of feeding arteries, middle cerebral artery feeding, volume, Feret diameter, surface area, roundness, elongation, mean density (HU), and median density (HU) were found by univariate analysis (p &lt; 0.05). The prediction model consisted of associated aneurysm, deep located, number of draining veins, deep drainage, Dv, volume, Feret diameter, surface area, mean density, and median density. The model showed good discrimination, with a C-index of 0.873 (95% CI, 0.791–0.931) in the training set and 0.754 (95% CI, 0.710–0.795) in the testing set.

Conclusions

This study presented 3D morphological features could be conveniently used to predict hemorrhage from unruptured bAVMs.

Endovascular embolization for cases of 'hidden' pediatric cerebral arteriovenous malformations: A diagnostic & therapeutic challenge

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.

Risk of early failure of VP shunts implanted for hydrocephalus after craniotomies for brain tumors in adults

Risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p < 0.001), but there was no significant difference with respect to early shunt failure. Median time from shunt insertion to shunt failure was 20 days (range 1–35). At 90 days, 17 patients (20%) had confirmed shunt failure. Patient age, sex, tumor location, primary/secondary craniotomy, extra-axial/intra-axial tumor, ventricular entry, post-craniotomy bleeding, and infection did not show statistical significance. The risk of early shunt failure (within 90 days) of shunts after craniotomies for brain tumors was 20%. This study can serve as benchmark for future studies.

Acute surgical management of children with ruptured brain arteriovenous malformation

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.

Secondary S100B Protein Increase Following Brain Arteriovenous Malformation Rupture is Associated with Cerebral Infarction

Early S100B protein serum elevation is associated with poor prognosis in patients with ruptured brain arteriovenous malformations (BAVM). The purpose of this study is to determine whether a secondary elevation of S100B is associated with early complications or poor outcome in this population. This is a retrospective study of patients admitted for BAVM rupture. A secondary increase of S100B was defined as an absolute increase by 0.1 μg/L within 30 days of admission. Fisher’s and unpaired t tests followed by multivariate analysis were performed to identify markers associated with this increase. Two hundred and twenty-one ruptures met inclusion criteria. Secondary S100B protein serum elevation was found in 17.1% of ruptures and was associated with secondary infarction (p < 0.001), vasospasm-related infarction (p < 0.001), intensive care (p = 0.009), and hospital length of stay (p = 0.005), but not with early rebleeding (p = 0.07) or in-hospital mortality (p = 0.99). Secondary infarction was the only independent predictor of secondary increase of S100B (OR 9.9; 95% CI (3–35); p < 0.001). Secondary elevation of S100B protein serum levels is associated with secondary infarction in ruptured brain arteriovenous malformations.

Hydrocephalus in children with ruptured cerebral arteriovenous malformation

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.

Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations

Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.

Timing of surgery for ruptured supratentorial arteriovenous malformations

BACKGROUND

There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome.

OBJECTIVE

To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery.

METHODS

We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2-4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome).

RESULTS

Age over 40 years (OR 18.4; 95% CI 1.9-172.1; p = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1-89.2; p = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8-94.4; p = 0.011), and over 400 cm³ bleeding during surgery (OR 11.5; 95% CI 1.5-86.6; p = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6-1524.9; p = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4-829.9; p = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6-332.6; p = 0.007), and over 400 cm³ bleeding during surgery (OR 35.3; 95% CI 1.7-748.7; p = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2-55.7; p = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3-24.3; p = 0.019), and over 400 cm³ bleeding during surgery (OR 5.8; 95% CI 1.2-27.3; p = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome.

CONCLUSIONS

Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.

Outcomes after intracerebral hemorrhage from arteriovenous malformations

OBJECTIVE

To compare outcomes after intracerebral hemorrhage (ICH) from cerebral arteriovenous malformation (AVM) rupture and other causes of ICH.

METHODS

We performed a retrospective population-based study using data from the Nationwide Inpatient Sample. We used standard diagnosis codes to identify ICH cases from 2002 to 2011. Our predictor variable was cerebral AVM. Our primary outcomes were inpatient mortality and home discharge. We used logistic regression to compare outcomes between patients with ICH with and without AVM while adjusting for demographics, comorbidities, and hospital characteristics. In a confirmatory analysis using a prospective cohort of patients hospitalized with ICH at our institution, we additionally adjusted for hematoma characteristics and the Glasgow Coma Scale score.

RESULTS

Among 619,167 ICH hospitalizations, the 4,485 patients (0.7%, 95% confidence interval [CI] 0.6-0.8) with an AVM were younger and had fewer medical comorbidities than patients without AVM. After adjustment for confounders, patients with AVM had lower odds of death (odds ratio [OR] 0.5, 95% CI 0.4-0.7) and higher odds of home discharge (OR 2.0, 95% CI 1.4-3.0) than patients without AVM. In a confirmatory analysis of 342 patients with ICH at our institution, the 34 patients (9.9%, 95% CI 7.2-13.6) with a ruptured AVM had higher odds of ambulatory independence at discharge (OR 4.4, 95% CI 1.4-13.1) compared to patients without AVM.

CONCLUSIONS

Patients with ICH due to ruptured AVM have more favorable outcomes than patients with ICH from other causes.

Retrospective study of long-term outcome after brain arteriovenous malformation rupture: the RAP score

OBJECTIVE The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome. METHODS The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality. RESULTS One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1-13.7, p < 10^-3), hematoma volume (OR 1.8, 95% CI 1.2-2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66-21, p < 10^-3) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8-0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85-0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6-87) and 90.8% (95% CI 81.9-96.2), respectively. CONCLUSIONS The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.

The natural history of cerebral arteriovenous malformations

Cerebral arteriovenous malformations (AVMs) are composed of a complex tangle of abnormal arteries and veins and are a significant source of cerebral hemorrhage and consequent morbidity and mortality in young adults, representing a diagnostic and therapeutic challenge. Current natural-history studies of cerebral AVMs report overall annual rates of 1% and 3% for the risk of epilepsy and hemorrhage, respectively. Unruptured AVMs have an annual hemorrhage rate of 2.2% while ruptured lesions have an annual hemorrhage rate of 4.5%. These hemorrhage rates are can change over time, particularly for hemorrhagic lesions, with the rebleed rate ranging from 6% to 15.8% in the first year after rupture across several studies. Besides hemorrhage, other significant risk factors for AVM hemorrhage include deep location, deep venous drainage, associated aneurysms, and pregnancy. Other factors include patient age, sex, and small AVM size, which are not currently considered significant risk factors for AVM hemorrhage. In addition to hemorrhage risk and seizure risk, the natural history of an AVM also encompasses the daily psychologic burden that a patient must endure knowing that he or she possesses an untreated AVM. This chapter reviews the epidemiology, clinical features, and natural history of cerebral AVMs.