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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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Oulasvirta E, Pohjola A, Koroknay-Pál P, Hafez A, Roine R, Sintonen H, Laakso A. Long-term health-related quality of life in patients with ruptured arteriovenous malformations treated in childhood. J Neurosurg Pediatr 2022; 30:292-300. [PMID: 35901751 DOI: 10.3171/2022.5.peds2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to reveal the long-term health-related quality of life (HRQOL), educational level, and impact on occupation in 55 patients who experienced ruptured brain arteriovenous malformations (AVMs) that were treated during childhood. METHODS In 2016, questionnaires including the 15D instrument were sent to all living patients older than 18 years (n = 432) in the Helsinki AVM database. The cohort was further specified to include only patients with ruptured AVMs who were younger than 20 years at the time of diagnosis (n = 55). Educational level was compared with the age-matched general population of Finland. The mean 15D scores were calculated for independent variables (Spetzler-Ponce classification, admission age, symptomatic epilepsy, and multiple bleeding episodes) and tested using the independent-samples t-test or ANCOVA. Linear regression was used to create a multivariate model. Bonferroni correction was used with multiple comparisons. RESULTS The mean follow-up time from diagnosis to survey was 24.2 (SD 14.7) years. The difference in the mean 15D scores between Spetzler-Ponce classes did not reach statistical significance. The youngest age group (< 10 years at the time of diagnosis) performed less well on the dimension of usual activities than the older patients. Symptomatic epilepsy significantly reduced the long-term HRQOL. Multiple hemorrhages significantly reduced the scores on three dimensions: mobility, speech, and sexual activity. In the regression model, symptomatic epilepsy was the only significant predictor for a lower 15D score. The educational level of the cohort was for the most part comparable to that of the general population in the same age group. AVM was the reason for early retirement in 11% of the patients, while lowered performance because of the AVM was reported by 37% of the patients. CONCLUSIONS Patients with ruptured AVMs treated in childhood can live an independent and meaningful life, even in the case of the highest-grade lesions. Symptomatic epilepsy significantly reduced the long-term HRQOL, highlighting the need for continuing support for these patients.
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Affiliation(s)
- Elias Oulasvirta
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Anni Pohjola
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Päivi Koroknay-Pál
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Ahmad Hafez
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Risto Roine
- 2Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland; and
| | - Harri Sintonen
- 3Department of Public Health, Helsinki University Hospital, Helsinki, Finland
| | - Aki Laakso
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage. Pediatr Res 2022; 91:1238-1247. [PMID: 34215837 DOI: 10.1038/s41390-021-01631-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 06/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Greater ventriculomegaly in preterm infants with intraventricular hemorrhage (IVH) has been associated with worse neurodevelopmental outcomes in infancy. We aim to explore the relationship between ventriculomegaly and school-age functional outcome. METHODS Retrospective review of preterm infants with Grade III/IV IVH from 2006 to 2020. Frontal-occipital horn ratio (FOHR) was measured on imaging throughout hospitalization and last available follow-up scan. Pediatric Cerebral Performance Category (PCPC) scale was used to assess functional outcome at ≥4 years. Ordinal logistic regression was used to determine the relationship between functional outcome and FOHR at the time of Neurosurgery consult, neurosurgical intervention, and last follow-up scan while adjusting for confounders. RESULTS One hundred and thirty-four infants had Grade III/IV IVH. FOHR at consult was 0.62 ± 0.12 and 0.75 ± 0.13 at first intervention (p < 0.001). On univariable analysis, maximum FOHR, FOHR at the last follow-up scan, and at Neurosurgery consult predicted worse functional outcome (p < 0.01). PVL, longer hospital admission, and gastrotomy/tracheostomy tube also predicted worse outcome (p < 0.05). PVL, maximum FOHR, and FOHR at consult remained significant on multivariable analysis (p < 0.05). Maximum FOHR of 0.61 is a fair predictor for moderate-severe impairment (AUC 75%, 95% CI: 62-87%). CONCLUSIONS Greater ventricular dilatation and PVL were independently associated with worse functional outcome in Grade III/IV IVH regardless of neurosurgical intervention. IMPACT Ventriculomegaly measured by frontal-occipital horn ratio (FOHR) and periventricular leukomalacia are independent correlates of school-age functional outcomes in preterm infants with intraventricular hemorrhage regardless of need for neurosurgical intervention. These findings extend the known association between ventriculomegaly and neurodevelopmental outcomes in infancy to functional outcomes at school age. FOHR is a fair predictor of school-age functional outcome, but there are likely other factors that influence functional status, which highlights the need for prospective studies to incorporate other clinical and demographic variables in predictive models.
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Lamparyk K, Burkhart K, Buzenski J, van Tilburg MAL. Challenges and opportunities in measuring the pediatric quality of life: exemplified by research in pediatric gastroenterology. Expert Rev Pharmacoecon Outcomes Res 2021; 21:211-219. [PMID: 33478299 DOI: 10.1080/14737167.2021.1879643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Quality of life (QOL) is an important patient-reported outcome measure (PROM). Assessment of QOL in children is challenging particularly because developmental age affects the accuracy of self-reports.Areas covered: This paper gives an overview and expert opinion of the factors impacting quality assessment of pediatric QOL. Given this literature is vast, we focused on QOL measurement in pediatric gastroenterological conditions as an example, but the general principles apply across childhood chronic diseases. Child developmental stage affects self-reports. Younger children are less reliable reporters implicating the need for parental proxies. However, parents may not be as cognizant of their child's internal life especially as the child grows older. Adjustment to disease (QOL initially decreases then improves) as well as the time of year (QOL improves during summer) affects reports of QOL. Furthermore, it is important to acknowledge the impact of the child's disease on caregivers and families' QOL.Expert opinion: The numerous aspects impacting pediatric QOL make assessment and measurement complex. We propose several strategies to guide this process such as assessing both self-report and parent-proxy measures, as well as considering the timing of QOL assessments.
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Affiliation(s)
- Katherine Lamparyk
- Center for Pediatric Behavioral Health, Cleveland, Cleveland Clinic Children's Hospital, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH, USA
| | - Kimberly Burkhart
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jessica Buzenski
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, US
| | - Miranda A L van Tilburg
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA.,University of Washington, School of Social Work, Seattle, WA, USA.,Department of Clinical Research, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC, USA
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Zimmerman JJ, Banks R, Berg RA, Zuppa A, Newth CJ, Wessel D, Pollack MM, Meert KL, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Wong H, Chima RS, Holubkov R, Coleman W, Sorenson S, Varni JW, McGalliard J, Haaland W, Whitlock K, Dean JM, Reeder RW. Critical Illness Factors Associated With Long-Term Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock. Crit Care Med 2020; 48:319-328. [PMID: 32058369 DOI: 10.1097/ccm.0000000000004122] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES A companion article reports the trajectory of long-term mortality and significant health-related quality of life disability among children encountering septic shock. In this article, the investigators examine critical illness factors associated with these adverse outcomes. DESIGN Prospective, cohort-outcome study, conducted 2013-2017. SETTING Twelve United States academic PICUs. PATIENTS Critically ill children, 1 month to 18 years, with community-acquired septic shock requiring vasoactive-inotropic support. INTERVENTIONS Illness severity, organ dysfunction, and resource utilization data were collected during PICU admission. Change from baseline health-related quality of life at the month 3 follow-up was assessed by parent proxy-report employing the Pediatric Quality of Life Inventory or the Stein-Jessop Functional Status Scale. MEASUREMENTS AND MAIN RESULTS In univariable modeling, critical illness variables associated with death and/or persistent, serious health-related quality of life deterioration were candidates for multivariable modeling using Bayesian information criterion. The most clinically relevant multivariable models were selected among models with near-optimal statistical fit. Three months following septic shock, 346 of 389 subjects (88.9%) were alive and 43 of 389 had died (11.1%); 203 of 389 (52.2%) had completed paired health-related quality of life surveys. Pediatric Risk of Mortality, cumulative Pediatric Logistic Organ Dysfunction scores, PICU and hospital durations of stay, maximum and cumulative vasoactive-inotropic scores, duration of mechanical ventilation, need for renal replacement therapy, extracorporeal life support or cardiopulmonary resuscitation, and appearance of pathologic neurologic signs were associated with adverse outcomes in univariable models. In multivariable regression analysis (odds ratio [95% CI]), summation of daily Pediatric Logistic Organ Dysfunction scores, 1.01/per point (1.01-1.02), p < 0.001; highest vasoactive-inotropic score, 1.02/per point (1.00-1.04), p = 0.003; and any acute pathologic neurologic sign/event, 5.04 (2.15-12.01), p < 0.001 were independently associated with death or persistent, serious deterioration of health-related quality of life at month 3. CONCLUSIONS AND RELEVANCE Biologically plausible factors related to sepsis-associated critical illness organ dysfunction and its treatment were associated with poor outcomes at month 3 follow-up among children encountering septic shock.
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Affiliation(s)
- Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Russell Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Newth
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA
| | - David Wessel
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Murray M Pollack
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
| | - Mark W Hall
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Michael Quasney
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Colorado, Denver, CO
| | - Hector Wong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Ranjit S Chima
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Richard Holubkov
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Whitney Coleman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Samuel Sorenson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James W Varni
- Department of Landscape Architecture and Urban Planning, Texas A&M University, College Station, TX
| | - Julie McGalliard
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Wren Haaland
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathryn Whitlock
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - J Michael Dean
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
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Lu VM, Wahood W, Rinaldo L, Ahn ES, Daniels DJ. Long-term functional outcome after intervention for pediatric intracranial arteriovenous malformations: A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 191:105707. [PMID: 32018117 DOI: 10.1016/j.clineuro.2020.105707] [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: 07/19/2019] [Revised: 11/15/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
Intervention (surgery, embolization, and radiosurgery) is critical in maximizing outcomes of pediatric arteriovenous malformations (pAVMs). Although short-term functional outcomes following intervention have been stablished to be favorable, long-term outcomes have yet to be thoroughly consolidated. Searches of 7 electronic databases from inception to April 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Favorable functional were modified Rankin Scale (mRS) scores ranging from 0 to 2, and the incidences were extracted and pooled by random-effects meta-analysis of proportions. Fourteen pertinent studies were identified describing outcomes of 699 pAVM patients, with median 75 % presenting with hemorrhage. Surgery, embolization and radiosurgery use were reported by 12 (86 %), 14 (100 %) and 10 (71 %) studies respectively. By median study follow-up time of 4.1 years, a favorable functional outcome was estimated to occur in 87 % (95 % CI, 82-91 %) of subjects respectively. Hemorrhagic versus non-hemorrhagic presentations did not statistically differ in incidence of this long-term outcome, 78 % (95 % CI, 67-87 %) and 91 % (95 % CI, 80-98 %) respectively. This study demonstrates that favorable long-term functional outlook of pAVM subjects after intervention can persist for many years after initial intervention. The certainty of achieving this outcome is moderate, irrespective of hemorrhagic presentation or intervention modality. Long-term functional deficit risk should not be the sole factor in deciding if intervention should be pursued.
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Affiliation(s)
- Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
| | - Waseem Wahood
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
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Giorgi L, Durand P, Morin L, Miatello J, Merchaoui Z, Lambert V, Boithias C, Senat MV, Stos B, Maurey H, Adamsbaum C, Tissières P, Saliou G, Spelle L, Ozanne A. Management and Outcomes of Neonatal Arteriovenous Brain Malformations with Cardiac Failure: A 17 Years' Experience in a Tertiary Referral Center. J Pediatr 2020; 218:85-91.e2. [PMID: 31870606 DOI: 10.1016/j.jpeds.2019.10.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/27/2019] [Accepted: 10/31/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the management and outcomes of neonatal arteriovenous brain malformations (mostly vein of Galen malformations) complicated by cardiac failure in the era of prenatal diagnosis and endovascular treatment in a tertiary referral center. STUDY DESIGN This observational study included 77 living newborn infants with arteriovenous brain malformations with cardiac failure, admitted to our referral center from 2001 to 2017. All infants underwent cardiovascular evaluation including echocardiogram and brain magnetic resonance imaging. Long-term survivors had standard neurocognitive assessments. RESULTS Infants were admitted to the neonatal intensive care unit at a median of 5 days of age (including 18 inborn patients since 2009). Sixty transarterial shunt embolizations were performed in 46 patients during their first month (at a median age of 7.5 days) or postponed beyond the first month in another 10 long-term survivors. Embolization was not performed in 21 infants, including 19 nonsurvivors with severe brain injury, uncontrolled cardiac failure, or multiple organ failure. Cardiac failure requiring vasopressor infusion occurred in 48 patients (64%) during the hospitalization. Infants who survived the first month underwent a median of 3 embolization sessions. Among the 51 survivors, 21 had a good outcome and 19 had a poor outcome at follow-up (median age, 5.3 years); 11 children were lost to follow-up. CONCLUSIONS In the era of multidisciplinary prenatal diagnosis, using a standardized care protocol, 47% of liveborn infants with an arteriovenous shunt malformation with cardiac failure experienced a favorable outcome.
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Affiliation(s)
- Laetitia Giorgi
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France; Department of Pediatrics Neurology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance Publique Hôpitaux de Paris, France
| | - Phillippe Durand
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France.
| | - Luc Morin
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Jordi Miatello
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Zied Merchaoui
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Virginie Lambert
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Claire Boithias
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Marie Victoire Senat
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Bertrand Stos
- Department of Obstetrics and Gynecology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Hélène Maurey
- Department of Pediatrics Neurology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance Publique Hôpitaux de Paris, France
| | - Catherine Adamsbaum
- Department of Pediatrics Radiology, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Pierre Tissières
- Division of Pediatrics and Neonatal Intensive Care, Paris-Saclay University Hopsitals, Bicêtre Medical center Assistance publique-hôpitaux de Paris, France
| | - Guillaume Saliou
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France; Department of Diagnostic and Interventional Neuroradiology, Lausanne University Hospital, CHUV-UNIL, Lausanne, Switzerland
| | - Laurent Spelle
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
| | - Augustin Ozanne
- Department of Interventional Neuroradiology Neuro Brain vascular center, Paris-Saclay University Hospitals, Bicêtre medical center, Assistance publique-hôpitaux de Paris, France
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8
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Pohjola A, Oulasvirta E, Roine RP, Sintonen HP, Hafez A, Koroknay-Pál P, Lehto H, Niemelä M, Laakso A. Long-term health-related quality of life in 262 patients with brain arteriovenous malformation. Neurology 2019; 93:e1374-e1384. [PMID: 31511351 DOI: 10.1212/wnl.0000000000008196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/05/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To discover the health-related quality of life (HRQOL) of patients with treated arteriovenous malformation (AVM), we used the self-applicable HRQOL instrument, the 15D, and analyzed the scores in both in the whole study population and specified cohorts. METHODS The 15D questionnaires were mailed to adult patients with AVM alive in 2016 (n = 432) in our database. Patients with completely eradicated AVM (n = 262) were included in a subsequent analysis. The results were compared with those of the general population standardized for age and sex. Subgroup analyses were conducted for epilepsy, number of bleeding episodes, location of the lesion, modified Rankin Scale score, and Spetzler-Ponce classification (SPC) using independent-samples t test or analysis of covariance. Tobit regression was used to explain the variance in the 15D score. RESULTS Patients had impaired HRQOL compared to the reference population (p < 0.0001). Deep location, multiple bleeding episodes, and refractory epilepsy were associated with impaired HRQOL. Patients in SPC A and B had similar posttreatment 15D scores, whereas those in class C had an impaired HRQOL. Significant explanatory variables in the regression model were age, sex, number of bleeding episodes, refractory epilepsy, and SPC. CONCLUSIONS With careful patient selection, patients in SPC B can reach as favorable HRQOL as those in SPC A provided the operation is successful. Multiple bleeding episodes should be prevented with effective treatment aiming at complete AVM obliteration. The postoperative treatment of patients with AVM should focus on preventing depressive symptoms, anxiety, and epileptic seizures. We encourage other research groups to use HRQOL instruments to fully understand the consequences of neurologic and neurosurgical diseases on patients' HRQOL.
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Affiliation(s)
- Anni Pohjola
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Elias Oulasvirta
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Risto P Roine
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Harri P Sintonen
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Ahmad Hafez
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Päivi Koroknay-Pál
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Hanna Lehto
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Mika Niemelä
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland
| | - Aki Laakso
- From the Department of Neurosurgery (A.P., E.O., A.H. P.K-P., H.L., M.N., A.L.), Helsinki University Hospital; Group Administration (R.P.R.), University of Helsinki and Helsinki University Hospital; Department of Health and Social Management (R.P.R.), University of Eastern Finland, Kuopio; and Department of Public Health (H.P.S.), University of Helsinki, Finland.
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9
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Dinc N, Won SY, Eibach M, Gessler F, Konczalla J, Quick-Weller J, Seifert V, Marquardt G. The Extent of Neurologic Improvement and Social Life in Young Patients with Ruptured and Unruptured Brain AVM: A Long-Term Follow-Up. World Neurosurg 2019; 127:e503-e508. [PMID: 30928578 DOI: 10.1016/j.wneu.2019.03.187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/16/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intracerebral hemorrhage, seizures, neurologic deficits, and cognitive impairments due to brain AVM in childhood are incriminating for brain and executive function with sequelae for further social life. Long-term follow-up data on brain AVM in young patients are rare, making it difficult to compare and evaluate treatment risks and outcomes. METHODS We studied young patients with brain AVM who were referred to our institution between 2005 and 2012 and for whom follow-up data were available. We stratified the patients into those with ruptured AVM (rAVM) and unruptured AVM (uAVM) and compared treated and nontreated patients. Differences in outcome and social participation were assessed. RESULTS A total of 29 young patients with brain AVM, median age 16 years, were included in our study with complete follow-up data of over 5 years (mean, 6 years). In 18 (62.1%) patients rAVM and in 11 (37.9%) patients uAVM were found. Twenty (69%) patients received treatment (rAVM 70% vs. uAVM 30%). Among treatment methods, microsurgery was most frequently used (rAVM 33.3% vs. uAVM 36.4%). In rAVM, 16 of 18 (88.9%) patients returned to work or school, and in uAVM, 11 (100%) patients did so. Concerning cognitive problems, no statistically significant difference was found in the 2 groups comparing treated and nontreated patients (P > 0.05). A favorable outcome was achieved in 13 (72.2%) patients with rAVM and in 11 (100%) patients with uAVM. CONCLUSION Favorable outcome was achieved in the majority of patients. The rate of neurologic improvement and participation in social life was very high in the 2 groups.
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Affiliation(s)
- Nazife Dinc
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany.
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Michael Eibach
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | | | - Volker Seifert
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Gerhard Marquardt
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
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10
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Ai X, Ye Z, Xu J, You C, Jiang Y. The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis. J Neurosurg Pediatr 2018; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/06/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs. METHODS The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients. CONCLUSIONS Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation. ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; NOS = Newcastle-Ottawa Scale; OR = odds ratio; SM = Spetzler-Martin.
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Affiliation(s)
| | | | | | | | - Yan Jiang
- 2Nursing Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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11
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van Essen MJ, Han KS, Lo RTH, Woerdeman P, van der Zwan A, van Doormaal TPC. Functional and educational outcomes after treatment for intracranial arteriovenous malformations in children. Acta Neurochir (Wien) 2018; 160:2199-2205. [PMID: 30191363 PMCID: PMC6209013 DOI: 10.1007/s00701-018-3665-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/31/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in the pediatric population are rare, yet they form the most frequent cause of hemorrhagic stroke in children. Compared to adults, children have been suggested to have beneficial neurological outcomes. However, few studies have focused on other variables than neurological outcomes. This study aims to assess the long-term functional and educational outcomes of children after multimodality approach of treatment for intracranial AVMs. METHODS All children treated in our center between 1998 and 2016 for intracranial AVMs were reviewed. Patient characteristics, as well as AVM specifics, were collected. Functional outcomes were compared using the modified Rankin scale (mRs). Educational levels, using the International Standard Classification of Education (ISCED), were compared to the age-matched general population of the Netherlands. RESULTS In total, 25 children were included at mean age of 10 years (range 2-16 years). Nineteen patients (76%) presented with intracranial bleeding. Mean follow-up was 11.5 ± 5.3 years (range 4.1-24.4). Four (16%) of patients were treated with embolization, three (12%) with microsurgery, and 18 patients (72%) received a combination of different treatment modalities. Altogether, 21 (84%) were embolized, 14 (56%) were treated with microsurgery, and eight (32%) received stereotactic radiosurgery. One child had a worse mRs at discharge compared to admission; all others improved (n = 11) or were stable (n = 13). At follow-up, all patients scored a stable or improved mRs compared to discharge, with 23 children (92%) scoring mRs 0 or 1. These 23 children followed regular education during follow-up without specialized or adapted schooling. No significant differences in educational level with the age-matched general population were found. CONCLUSION This retrospective review shows positive long-term results of both functional and educational outcomes after multidisciplinary treatment of pediatric brain AVMs.
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Affiliation(s)
- Max J van Essen
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kuo Sen Han
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rob T H Lo
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan, 100, Utrecht, The Netherlands
| | - Peter Woerdeman
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Albert van der Zwan
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Brain Technology Institute, Yalelaan, 44, Utrecht, The Netherlands
| | - Tristan P C van Doormaal
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Brain Technology Institute, Yalelaan, 44, Utrecht, The Netherlands.
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12
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Stein KP, Huetter BO, Goericke S, Oezkan N, Leyrer R, Sandalcioglu IE, Forsting M, Sure U, Mueller O. Cerebral arterio-venous malformations in the paediatric population: Angiographic characteristics, multimodal treatment strategies and outcome. Clin Neurol Neurosurg 2017; 164:164-168. [PMID: 29245106 DOI: 10.1016/j.clineuro.2017.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 11/04/2017] [Accepted: 12/03/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Cerebral arterio-venous malformations (AVM) are considered congenital lesions, emerging as an important cause of haemorrhagic stroke in children. The potential influence of age on clinical presentation and angio-architecture have been analysed extensively in the last years. Yet, comparative studies comprising ascending age groups may be limited in their conclusions, especially when comparing young children and adults. It is the aim of this study to evaluate characteristic clinical and angiographic features of AVM within a paediatric subgroup and their correlation to age at presentation. PATIENTS AND METHODS Between 1990-2015, 46 children harbouring AVMs were treated at our institution. Clinical presentation, radiological data, treatment strategies and outcome were evaluated retrospectively. RESULTS Of 46 consecutive patients, 18 were male and 28 female patients. Mean age was 11.6±4.3years, ranging from 2 to 17 years. 35 patients (76%) presented with haemorrhage. Seizures were found in 6 patients (13%) and progressive or transient focal neurological deficits in 4 individuals (9%). There was one incidental patient, only. Mean age of children presenting with haemorrhage was significantly lower as compared to those without a history of intracranial bleeding (p=0.1). The size of the AVM was small (n=27, 59%), corresponding a grade I AVM in the majority of patients (N=28, 61%). 41 patients (89%) underwent treatment of their AVM by an interdisciplinary approach achieving complete elimination of the lesion in 34 patients (83%). 34 patients (83%) showed at least a favourable outcome (mRS≤2) at last follow-up. An excellent recovery (mRS 0-1) was noted in 28 patients (68%). CONCLUSION From our data we suggest that patients' age impacts the clinical presentation. Particularly young children seem to bear a higher risk for haemorrhage from their AVM. Treatment of paediatric AVMs can be achieved safely in experienced hands with a high rate of complete elimination and good clinical outcome.
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Affiliation(s)
- Klaus-Peter Stein
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany; Department of Neurosurgery, KRH Hospital Nordstadt, Haltenhoffstr.41, 30167 Hannover, Germany.
| | - Bernd-Otto Huetter
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Sophia Goericke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Neriman Oezkan
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Rebecca Leyrer
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, KRH Hospital Nordstadt, Haltenhoffstr.41, 30167 Hannover, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
| | - Oliver Mueller
- Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
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13
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MURPHY LEXAK, COMPAS BRUCEE, GINDVILLE MELISSAC, REESLUND KRISTENL, JORDAN LORIC. Cognitive functioning over 2 years after intracerebral hemorrhage in school-aged children. Dev Med Child Neurol 2017; 59:1146-1151. [PMID: 28877339 PMCID: PMC5679061 DOI: 10.1111/dmcn.13547] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2017] [Indexed: 12/11/2022]
Abstract
AIM Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke. METHOD Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed. RESULTS PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers. INTERPRETATION Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function. WHAT THIS PAPER ADDS In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children.
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Affiliation(s)
- LEXA K MURPHY
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN
| | - BRUCE E COMPAS
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN,Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - MELISSA C GINDVILLE
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - KRISTEN L REESLUND
- Department of Pediatrics, Division of Developmental Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - LORI C JORDAN
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
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14
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Shtaya A, Millar J, Sparrow O. Multimodality management and outcomes of brain arterio-venous malformations (AVMs) in children: personal experience and review of the literature, with specific emphasis on age at first AVM bleed. Childs Nerv Syst 2017; 33:573-581. [PMID: 28324183 PMCID: PMC5382178 DOI: 10.1007/s00381-017-3383-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/10/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this paper is to study the presentation and analyse the results of multimodality treatment of brain arterio-venous malformations (AVMs) in children at our centre and review age at first AVM rupture in the literature. METHODS Of 52 patients aged <18 years, 47 with brain AVMs (27 males and 20 females) aged 4-17 years (mean 12.2) were retrospectively reviewed. PubMed search revealed five additional studies including 267 patients where the prevalence of age-related AVMs rupture was analysed. RESULTS In our study, 37 patients had bled, 9 were symptomatic without haemorrhage and 1 was incidental. Spetzler-Martin score distribution was 5 cases grade I, 18 grade II, 21 grade III and 3 grade IV. Appropriate imaging was performed, either CT/MRI angiogram only (in emergency cases) or catheter angiogram, prior to definitive treatment. There were 40 supratentorial and 7 infratentorial AVMs. Twenty-nine patients had microsurgery alone and 9 patients were treated by radiosurgery only. Three patients were embolised, all followed by radiosurgery, with one requiring surgery too, while 4 patients had combined surgery and radiosurgery. One patient is awaiting radiosurgery while another was not treated. Good outcomes, classified as modified Rankin score (mRS) 0-2 improved significantly after intervention to 89.4% from 38.3% pre-treatment (p value <0.0001). Angiography confirmed 96.6% obliteration after first planned operation. Repeat cerebral angiogram around age 18 was negative in all previously cured patients. Reviewing the literature, 82.0% (95% CI = [77-87]; N = 267) of children diagnosed with brain AVMs (mean age 11.4 ± 0.4) presented with a bleed in the last 22 years. Males significantly outnumbered females (136 vs 84) (p < 0.001). Ninety-five patients underwent surgical intervention alone when compared to other treatment modalities (p < 0.001). CONCLUSIONS Microsurgical excision of surgically accessible intracranial AVMs remains the primary treatment option with very good outcomes. A significant number of patients' AVMs ruptured around puberty; therefore, understanding the pathophysiology of AVM instability at this age may aid future therapy.
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Affiliation(s)
- Anan Shtaya
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK. .,Atkinson Morley Neurosurgery Centre, Academic Neurosurgery Unit, St George's, University of London, London, SW17 0RE, UK.
| | - John Millar
- 0000000103590315grid.123047.3Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Owen Sparrow
- 0000000103590315grid.123047.3Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
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