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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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Oomori M, Ito S, Higuchi K. Fatal ruptured occult arteriovenous malformation in a young adult: An autopsy case report. Surg Neurol Int 2022; 13:284. [PMID: 35855123 PMCID: PMC9282792 DOI: 10.25259/sni_427_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Brain arteriovenous malformations (AVMs) are congenital developmental disorders with unclear causative factors and pathogenic mechanisms. Various epigenetic factors may influence the development and rupture of AVMs. Ruptured AVMs may lead to poor outcomes. Therefore, the risk factors of AVM rupture and treatment strategies for unruptured AVMs should be explored. Herein, we report a case of a fatal ruptured AVM diagnosed by radiological and autopsy findings and review the literature regarding AVM treatment.
Case Description:
A 46-year-old man was brought to the hospital with sudden loss of consciousness while sitting on the edge of the bathtub. On examination, he was unconscious with poor breathing efforts. He was intubated and a brain CT scan was performed, which showed an intracerebral hemorrhage (ICH) adjacent to the right trigone with massive intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Contrast-enhanced CT scan showed abnormal vessels adjacent to the hematoma. He was diagnosed with ICH associated with IVH and SAH caused by a ruptured abnormal vascular lesion. He underwent external ventricular drainage to control the intracranial pressure. He remained unconscious and died 16 h after hospital admission. Autopsy was performed to identify the cause of ICH. Pathological sections showed a mass of blood vessels, measuring 20 × 10 × 10 mm in size, within the hematoma with a single drainer connecting to the transverse sinus. These blood vessels had variable size, shape, and wall thickness on microscopy. Some vessels had abnormal thickened walls with discontinuous elastic fibers. Based on the radiological and autopsy findings, an ICH secondary to SpetzlerMartin Grade I AVM was confirmed.
Conclusion:
If the cause of ICH cannot be determined during a patient’s life, autopsy may be performed to determine the pathophysiology of occult vascular lesions, including AVMs. Patients with AVMs may have moderate or no symptoms before and after rupture. Because deep AVMs fed by posterior circulation have high risk of bleeding, surgical intervention should be considered for these patients to prevent a poor outcome. Low-grade and paraventricular AVMs in a young adult may be successfully treated with multimodal surgery.
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Affiliation(s)
- Makiko Oomori
- Department of Residency, Japanese Red Cross Nagahama Hospital, Nagahama, Nagahama, Japan
| | - Sayaka Ito
- Department of Neurosurgery, Kohka Public Hospital, Kohka, Nagahama, Japan
| | - Kazushi Higuchi
- Department of Neurosurgery, Japanese Red Cross Nagahama Hospital, Nagahama, Japan
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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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Zhang XR, Zhang T, Huard LL, Villablanca JP, Vinters HV. Fatal intracranial hemorrhage from brain AVM in a 7-week-old infant: case report and recent literature review. Childs Nerv Syst 2020; 36:1563-1568. [PMID: 31974663 DOI: 10.1007/s00381-020-04515-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/12/2020] [Indexed: 12/21/2022]
Abstract
Brain arteriovenous malformations (AVMs) are vascular abnormalities that typically present with spontaneous hemorrhage, seizure, or as a mass lesion. Pediatric brain AVMs are rarely diagnosed but carry a higher rate of rupture. We report a 7-week-old infant with rapid fatal intracranial hemorrhage from an undiagnosed brain. AVM confirmed at autopsy. Literature review on pediatric patients who had acute death caused by previously undiagnosed brain AVM from 1992 to 2018 revealed that cerebellum is the most frequent location of such AVMs, followed by thalamus. All the children had extensive intracranial hemorrhage that led to their deterioration despite surgical intervention.
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Affiliation(s)
- Xinhai Robert Zhang
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - Ting Zhang
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Leanna L Huard
- Department of Pediatrics, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - J Pablo Villablanca
- Department of Radiological Science, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Harry V Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Oulasvirta E, Koroknay-Pál P, Hafez A, Elseoud AA, Lehto H, Laakso A. Characteristics and Long-Term Outcome of 127 Children With Cerebral Arteriovenous Malformations. Neurosurgery 2020. [PMID: 29518249 DOI: 10.1093/neuros/nyy008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Population-based long-term data on pediatric patients with cerebral arteriovenous malformations (AVMs) are limited. OBJECTIVE To clarify the characteristics and long-term outcome of pediatric patients with AVM. METHODS A retrospective analysis was performed on 805 consecutive brain AVM patients admitted to a single center between 1942 and 2014. The patients were defined as children if they were under 18 yr at admission. Children were compared to an adult cohort. Changing patterns of presentation were also analyzed by decades of admission. RESULTS The patients comprised 127 children with a mean age of 12 yr. The mean follow-up time was 21 yr (range 0-62). Children presented more often with intracerebral hemorrhage (ICH) but less often with epilepsy than adults. Basal ganglia, cerebellar, and posterior paracallosal AVMs were more common in pediatric than in adult patients. Frontal and temporal AVMs, in contrast, were more common in adult than in pediatric patients. As the number of incidentally and epilepsy-diagnosed AVMs increased, ICH rates dropped in both cohorts. In total, 22 (82%) pediatric and 108 (39%) adult deaths were assessed as AVM related. After multivariate analysis, small AVM size and surgical treatment correlated with a favorable long-term outcome. CONCLUSION Hemorrhagic presentation was more common in children than in adults. This was also reflected as lower prevalence of epileptic presentation in the pediatric cohort. Lobar and cortical AVM locations were less frequent, whereas deep and cerebellar AVMs were more common in children. Hemorrhagic presentation correlated negatively with incidentally and epilepsy-diagnosed AVMs. In children, AVM was a major cause of death, but in adults, other factors contributed more commonly to mortality.
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Affiliation(s)
- Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Hospital, and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Hospital, and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital, and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Ahmed Abou Elseoud
- Department of Diagnostic Radiology, Helsinki University Hospital, Finland
| | - Hanna Lehto
- Department of Neurosurgery, Helsinki University Hospital, and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital, and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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He Y, Ding Y, Bai W, Li T, Hui FK, Jiang WJ, Xue J. Safety and Efficacy of Transvenous Embolization of Ruptured Brain Arteriovenous Malformations as a Last Resort: A Prospective Single-Arm Study. AJNR Am J Neuroradiol 2019; 40:1744-1751. [PMID: 31537516 DOI: 10.3174/ajnr.a6197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/23/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The efficacy and safety of transvenous embolization for brain arteriovenous malformations remains unclear, given the very limited number of cases reported. This prospective study was performed to assess this technique in ruptured AVMs. MATERIALS AND METHODS Twenty-one consecutive patients with ruptured brain AVMs who underwent transvenous embolization were prospectively followed between November 2016 and November 2018. The Spetzler-Martin grade was I in 3 AVMs (14.3%), II in four (19.0%), III in eleven (52.4%), and IV in three (14.3%). The complete AVM occlusion rate was calculated from 6-month follow-up DSA images. Occurrence of hemorrhage and infarction after embolization was evaluated using CT and MR imaging within 1 month after the operation. The mRS was used to assess the functional outcomes. RESULTS Complete AVM nidus obliteration was shown in 16 (84%) of 19 patients with technically feasible AVMs immediately after embolization. One (5%) patient with a small residual nidus after treatment showed complete obliteration at 13-month follow-up. There were 5 hemorrhages and 1 infarction; 4 patients' symptoms improved gradually. The percentage of cases with mRS ≤ 2 rose from 57.1% (12/21) before embolization to 66.7% (14/21) at 1-month follow-up. Both the morbidity and mortality rates were 4.8% (1/21). CONCLUSIONS Transvenous embolization can be performed only in highly selected hemorrhagic brain AVMs with high complete obliteration rates, improved functional outcomes, and acceptable morbidity and mortality rates, but it should not be considered as a first-line treatment.
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Affiliation(s)
- Y He
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - Y Ding
- Department of Radiology (Y.D.), Mayo Clinic, Rochester, Minnesota
| | - W Bai
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - T Li
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
| | - F K Hui
- Department of Radiology (F.K.H.), Johns Hopkins Hospital, Baltimore, Maryland
| | - W-J Jiang
- Department of Vascular Neurosurgery (W.-J.J.), the PLA Rocket Force General Hospital, Beijing, China
| | - J Xue
- From the Department of Interventional Neuroradiology (Y.H., W.B., T.L., J.X.), Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, and Henan Provincial Neurointerventional Engineering Research Center, Zhengzhou, China
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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 2019; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Stefani MA, Sgarabotto Ribeiro D, Mohr JP. Grades of brain arteriovenous malformations and risk of hemorrhage and death. Ann Clin Transl Neurol 2019; 6:508-514. [PMID: 30911574 PMCID: PMC6414495 DOI: 10.1002/acn3.723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 11/13/2022] Open
Abstract
Objective To assess the relationship of the grade of unruptured and untreated Brain Arteriovenous Malformations (AVMs), with the risk of subsequent stroke and death during follow‐up. Methods This prospective study was drawn from a cohort of adult patients with unruptured AVMs, who participated in the conservative treatment arm (medical management only for headache or seizures) of the randomized clinical trial of unruptured brain AVMs (ARUBA study). The grade of AVMs (Spetzler–Martin scale) was dichotomized into categories: AVMs of grades I and II were considered low grade; AVMs of grades III and IV were considered high grade. There were no grade V AVM patients in ARUBA. The primary outcome was symptomatic stroke (hemorrhagic or ischemic – documented by imaging) or death. Results The conservative treatment group had 123 patients (“as treated” analysis). 71 (57.7%) had lesions characterized for this analysis as low‐grade lesions and 52 (42.2%) as high grade. From the total of 10 (8.13%) primary outcomes, three occurred (4.22%) in low‐grade AVMs and seven (13.46%) in high‐grade AVMs (P = 0.0942). Interpretation Statistical analysis of the cohort of patients with unruptured and untreated AVMs from ARUBA study showed that the graduation categories (Spetzler–Martin grades) were not associated with the outcome of subsequent stroke or death.
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Affiliation(s)
- Marco A Stefani
- Postgraduate Program in Surgical Sciences Faculty of Medicine Federal University of Rio Grande do Sul Porto Alegre Brazil.,Department of Morphological Sciences Institute of Basic Health Sciences Federal University of Rio Grande do Sul Porto Alegre Brazil.,Neurosurgeon at Moinhos de Vento Hospital Porto Alegre Brazil
| | - Diego Sgarabotto Ribeiro
- Postgraduate Program in Surgical Sciences Faculty of Medicine Federal University of Rio Grande do Sul Porto Alegre Brazil.,Radiologist and Neuroradiologist Porto Alegre Brazil
| | - Jay P Mohr
- Neurologist at the Institute of Neurology Columbia University Medical Center New York New York
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Li Z, Ma L, Wu C, Ma J, Chen X. Pediatric brain arteriovenous malformation unfavorable hemorrhage risk: extrapolation to a morphologic model. Chin Neurosurg J 2018; 4:15. [PMID: 32922876 PMCID: PMC7398325 DOI: 10.1186/s41016-018-0123-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022] Open
Abstract
Background Children with brain arteriovenous malformations (bAVM) are at risk of life-threatening hemorrhage contributing to unfavorable neurological deficit in their early lives. Our aim was to propose a classification system predicting the unfavorable hemorrhage in children with bAVM. Methods We identified all consecutive children admitted to our institution for bAVMs between July 2009 and August 2015. A hemorrhage event was defined as unfavorable when it is life-threatening (requiring emergent invasive intervention) or with post-hemorrhage mRS > 3. The effects of demographic characteristics and bAVM morphology on unfavorable hemorrhage risk were studied using univariate and multivariable regression analyses, followed by discrimination analysis using area under the receiver operating curve (AUROC) and 5-fold cross validation. Results A total of 162 pediatric bAVM cases were identified, unfavorable hemorrhage occurred in 49 (30.2%). Periventricular nidus location (HR, 4.46; 95%CI, 1.93–10.31; P < 0.001), non-temporal lobe location (HR, 2.72; 95%CI, 1.20–6.15; P = 0.02) and long pial draining vein (HR, 3.26; 95%CI, 1.53–6.97; P = 0.002) were independent predictors of an earlier unfavorable hemorrhage in pediatric bAVMs. We further classified the bAVM into three types: Type I, periventricular and non-temporal location (Ia, deep location; Ib, superificial location); Type II, with long pial draining vein and non-periventricular or temporal location; Type III, non-periventricular or temporal location without long draining vein. Predictive accuracy of this classification for unfavorable hemorrhage was assessed with AUROC of 0.77 (95% CI 0.69–0.85) and remained stable after cross validation. Conclusion A morphologic model based on nidus location and venous drainage might predict unfavorable hemorrhage in children with bAVM.
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Affiliation(s)
- Zongze Li
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China
| | - Li Ma
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Chunxue Wu
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jun Ma
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaolin Chen
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 People's Republic of China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
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10
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Ma L, Kim H, Chen XL, Wu CX, Ma J, Su H, Zhao Y. Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation. Cerebrovasc Dis 2017; 43:231-241. [PMID: 28241126 DOI: 10.1159/000458731] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 02/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Children with untreated brain arteriovenous malformations (bAVM) are at risk of encountering life-threatening hemorrhage very early in their lives. The primary aim of invasive treatment is to reduce unfavorable outcome associated with a bAVM rupture. A better understanding of the morbidity of bAVM hemorrhage might be helpful for weighing the risks of untreated bAVM and invasive treatment. Our aim was to assess the clinical outcome after bAVM rupture and identify features to predict severe hemorrhage in children. METHODS We identified all consecutive children admitted to our institution for bAVMs between July 2009 and December 2014. Clinical outcome after hemorrhagic presentation and subsequent hemorrhage was evaluated using the modified Rankin Scale (mRS) for children. The association of demographic characteristics and bAVM morphology with severe hemorrhage (mRS >3 or requiring emergency hematoma evacuation) was studied using univariate and multivariable regression analyses. A nomogram based on multivariable analysis was formulated to predict severe hemorrhage risk for individual patients. RESULTS A total of 134 patients were identified with a mean treatment-free follow-up period of 2.1 years. bAVM ruptured in 83 (62%) children: 82 had a hemorrhage at presentation and 6 of them experienced a recurrent hemorrhage during follow-up; 1 patient had other diagnostic symptoms but bled during follow-up. Among them, 49% (41/83) had a severe hemorrhage; emergency hematoma evacuation was required in 28% of them (23/83), and 24% (20/83) remained as disabled (mRS ≥3) at last follow-up. Forty-six percent (38/82) of children with hemorrhagic presentation were severely disabled (mRS >3). Forty-three percent (3/7) were severely disabled after subsequent hemorrhage. The annual rate of severe subsequent hemorrhage was 1% in the overall cohort and 3.3% in children with ruptured presentation. All the subsequent severe hemorrhage events occurred in children with severe hemorrhage history (7%, 3/41). Periventricular location, non-temporal lobe location, and long draining vein were predictors for severe hemorrhage in pediatric untreated bAVMs. A nomogram based on bAVM morphology was contracted to predict severe hemorrhage risk for individual patients, which was well calibrated and had a good discriminative ability (adjusted C-statistic, 0.72). CONCLUSIONS Evaluating bAVM morbidity and morphology might be helpful for weighing the risks of untreated bAVM in pediatric patients.
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Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. J Neurosurg Pediatr 2017; 19:127-135. [PMID: 27911248 DOI: 10.3171/2016.9.peds16283] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.
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Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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12
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Ma L, Chen XL, Chen Y, Wu CX, Ma J, Zhao YL. Subsequent haemorrhage in children with untreated brain arteriovenous malformation: Higher risk with unbalanced inflow and outflow angioarchitecture. Eur Radiol 2016; 27:2868-2876. [PMID: 27900505 DOI: 10.1007/s00330-016-4645-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/30/2016] [Accepted: 10/11/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Children with brain arteriovenous malformations (bAVMs) are at risk of life-threatening haemorrhage in their early lives. Our aim was to analyse various angioarchitectural features of bAVM to predict the risk of subsequent haemorrhage during follow-up in children. METHODS We identified all consecutive children admitted to our institution for bAVMs between July 2009 and September 2015. Children with at least 1 month of treatment-free follow-up after diagnosis were included in further analysis. Annual rates of AVM rupture as well as several potential risk factors for subsequent haemorrhage were analysed using Kaplan-Meier analyses and Cox proportional hazards regression models. RESULTS We identified 110 paediatric patients with a mean follow-up period of 2.1 years (range, 1 month-15.4 years). The average annual risk of haemorrhage from untreated AVMs was 4.3 % in children. No generalised venous ectasia in conjunction with fast arteriovenous shunt was predictive of subsequent haemorrhage (RR, 7.55; 95 % CI 1.96-29.06). The annual rupture risk was 11.1 % in bAVMs without generalised venous ectasia but with fast arteriovenous shunt. CONCLUSIONS bAVM angiographic features suggesting unbalanced inflow and outflow might be helpful to identify children at higher risk for future haemorrhage. KEY POINTS • Haemorrhage risk stratification is important for children with untreated brain AVM. • Angiographic features suggesting unbalanced inflow and outflow predict paediatric brain AVM haemorrhage. • Identifying AVMs with high rupture risk help patient selection and tailoring treatment.
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Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xiao-Lin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Chun-Xue Wu
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050
| | - Jun Ma
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.
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