Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation

Risk factors for bleeding in patients with arteriovenous malformations associated with intracranial aneurysms

BACKGROUND AND OBJECTIVES

Natural history of brain arteriovenous malformations (bAVMs) with associated intracranial aneurysms (IAs) reveals a higher rate of hemorrhage. We aimed to identify the prevalence and risk factors for hemorrhage in a subgroup of patients with bAVMs and associated arterial IAs.

METHODS

The authors conducted an international, bicentric retrospective study of patients with ruptured and unruptured bAVMs with associated IAs treated at tertiary centers between January 2013 and December 2022. Sociodemographic data, clinical characteristics, and radiological parameters in patients with bAVM and associated IAs were analyzed.

RESULTS

Of 944 patients with bAVM, 137 individuals with 191 associated arterial IAs were included in the final analysis. Bleeding presentation was documented in 85 cases (62.0%). The mean size of bAVM-associated IAs was 6.8 (SD = 4.8) mm. Multiple intracranial aneurysms (MIA) were present in 35 patients (25.5%). bAVM-associated IAs were classified as nidal in 19.0%, flow-related in 73.7%, and unrelated in 7.3% of cases. Univariate analysis revealed that arterial hypertension (odds ratio 4.37 [CI 1.52-12.57]; P =.004), history of smoking (odds ratio 5.77 [CI 1.26-26.53]; P =.013), and high-grade bAVMs (grades IV/V, odds ratio 0.35 [CI 0.15-0.87]; P =.02), were associated with a bleeding risk. In the multivariable analysis, only arterial hypertension remained significantly associated with the bleeding event (adjusted odds ratio 3.37 [CI 1.07-10.58]; P =.038).

CONCLUSIONS

Observational data from our large bicentric cohort of patients with bAVM and associated IAs identified arterial hypertension as a risk factor associated with an increased risk of bleeding.

TRIAL REGISTRATION

The study was approved by the Institutional Review Board (IRB) of the University Clinical Center of Vojvodina and the University of Duisburg-Essen (20-9288-BO).

Transorbital Neuroendoscopic Surgery: A Comprehensive Review for Managing Intracranial Lesions with Orbital Access

Transorbital Neuro Endoscopic Surgery (TONES) stands at the forefront of neurosurgical innovation, providing a transformative approach for accessing intricate intracranial vascular lesions within the orbit. The versatility of TONES extends beyond orbital confines, reaching into challenging territories such as the anterior cranial fossa, making it a promising option for lesions extending into the orbital region. This review explores the historical evolution, technical intricacies, and clinical applications of TONES, emphasizing its role in managing vascular lesions. The genesis of TONES aimed to overcome limitations inherent to traditional surgical approaches, offering equivalent visibility while minimizing invasiveness and complications associated with open skull base surgery. Introduced in 2007 by Moe, TONES has evolved into a minimally invasive access corridor, expanding the horizons of neurosurgery through refined instrumentation and advanced surgical techniques. In the context of intracranial vascular lesions, particularly arteriovenous malformations and cerebral cavernomas, TONES exhibits advantages over conventional methods. Its minimally invasive nature, reduced morbidity, and superior cosmetic outcomes position it as a viable alternative. However, meticulous planning, coordination, and adherence to sterile protocols are imperative. Preoperative imaging, intraoperative navigation, and customized bone defects tailored to lesion specifics contribute to procedural success. Complications associated with TONES procedures demand systematic categorization for proactive risk mitigation. From eyelid necrosis to trigeminal hypoesthesia, anticipating and addressing potential pitfalls require a multifaceted approach. Meticulous dissection techniques, intraoperative monitoring, and postoperative assessments are crucial components of risk reduction. In conclusion, TONES represents a paradigm shift in neurosurgical approaches to intracranial vascular lesions, showcasing its adaptability and precision.

A case series of gyrus rectus arteriovenous malformation: Clinical characteristics, angioarchitecture, microsurgical treatment, and outcome

Background

Gyrus rectus arteriovenous malformation (AVM) is one of the intricate pathologies that can lead to gyrus rectus hematoma. However, there is a paucity of research on this topic. This case series aims to delineate the characteristics of gyrus rectus AVMs, their outcomes, and treatment strategies.

Methods

We enrolled five cases of gyrus rectus AVM that presented to the Neurosurgery Teaching Hospital in Baghdad, Iraq. Patients with the presence of gyrus rectus AVM were analyzed according to the demographic data, clinical status, radiological imaging, and outcome.

Results

Of the total cases enrolled, all five cases were ruptured at the presentation. Most of the AVMs had arterial feeders from the anterior cerebral artery (80%) and superficial venous drainage through the anterior third of the superior sagittal sinus occurred in four cases (80%). Two of the cases were classified as Spetzler-Martin grade 1 AVMs, two were grade 2, and one was grade 3. With regard to the modified Rankin Score (mRS), four of them had a score of 0 after observation for 30, 18, 26, and 12 months, respectively, while one patient had an mRS score of 1 after 28 months of observation. All five cases presented with seizure and were all treated by surgical resection.

Conclusion

To the best of our knowledge, this is the second report documenting the features of gyrus rectus AVMs and the first one from Iraq. Further, research into gyrus rectus AVMs is required to help better characterize and enhance our knowledge on the outcomes of such lesions.

Neuromonitoring in Children with Cerebrovascular Disorders

BACKGROUND

Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis.

METHODS

Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders.

RESULTS

Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans.

CONCLUSIONS

Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.

Endothelial Rbpj deletion normalizes Notch4-induced brain arteriovenous malformation in mice

Upregulation of Notch signaling is associated with brain arteriovenous malformation (bAVM), a disease that lacks pharmacological treatments. Tetracycline (tet)-regulatable endothelial expression of constitutively active Notch4 (Notch4*tetEC) from birth induced bAVMs in 100% of mice by P16. To test whether targeting downstream signaling, while sustaining the causal Notch4*tetEC expression, induces AVM normalization, we deleted Rbpj, a mediator of Notch signaling, in endothelium from P16, by combining tet-repressible Notch4*tetEC with tamoxifen-inducible Rbpj deletion. Established pathologies, including AV connection diameter, AV shunting, vessel tortuosity, intracerebral hemorrhage, tissue hypoxia, life expectancy, and arterial marker expression were improved, compared with Notch4*tetEC mice without Rbpj deletion. Similarly, Rbpj deletion from P21 induced advanced bAVM regression. After complete AVM normalization induced by repression of Notch4*tetEC, virtually no bAVM relapsed, despite Notch4*tetEC re-expression in adults. Thus, inhibition of endothelial Rbpj halted Notch4*tetEC bAVM progression, normalized bAVM abnormalities, and restored microcirculation, providing proof of concept for targeting a downstream mediator to treat AVM pathologies despite a sustained causal molecular lesion.

Inflammatory Response in Patients with Spontaneous Intracranial Hemorrhages

Mortality and disability rates in spontaneous intracranial hemorrhages remain high despite medical advances. In recent decades, much attention has been paid to neuroinflammation as a typical response to brain damage. Inflammation plays an important role in the acute and chronic phases of the disease. The relationship between plasma and cerebrospinal fluid cytokines, as well as the factors affecting their ratios, is currently not completely clear.

The objective was to study the inflammatory response to spontaneous intracranial hemorrhage.

Subjects and Methods. 59 patients aged 18 to 72 years (48 ± 6) were enrolled in the study. Patients were admitted to the intensive care unit after an episode of spontaneous intracranial hemorrhage. The levels of interleukins in blood plasma were studied: 6, 8, 10, TNF-α, C-reactive protein,

blood leukocytes, and procalcitonin (by a semi-quantitative method). In the cerebrospinal fluid, the following parameters were evaluated: cytosis, protein, glucose, lactate, cytokines (6, 8, 10, TNF-α). Blood samples were collected on days 1, 2, 3, 5, 7, 9, 14, 21, 28, 35, and 45.

Results. Systemic inflammatory response developed in all patients from the first day of acute brain injury. The most significant response was formed by glial brain cells which was confirmed by high levels of cytokines in the cerebrospinal fluid, hundreds and thousands of times higher than blood levels of cytokines.

Conclusion. Levels of pro-inflammatory cytokines are predictors of an unfavorable outcome.

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Deep Learning Paradigm for Cardiovascular Disease/Stroke Risk Stratification in Parkinson's Disease Affected by COVID-19: A Narrative Review

Background and Motivation: Parkinson's disease (PD) is one of the most serious, non-curable, and expensive to treat. Recently, machine learning (ML) has shown to be able to predict cardiovascular/stroke risk in PD patients. The presence of COVID-19 causes the ML systems to become severely non-linear and poses challenges in cardiovascular/stroke risk stratification. Further, due to comorbidity, sample size constraints, and poor scientific and clinical validation techniques, there have been no well-explained ML paradigms. Deep neural networks are powerful learning machines that generalize non-linear conditions. This study presents a novel investigation of deep learning (DL) solutions for CVD/stroke risk prediction in PD patients affected by the COVID-19 framework. Method: The PRISMA search strategy was used for the selection of 292 studies closely associated with the effect of PD on CVD risk in the COVID-19 framework. We study the hypothesis that PD in the presence of COVID-19 can cause more harm to the heart and brain than in non-COVID-19 conditions. COVID-19 lung damage severity can be used as a covariate during DL training model designs. We, therefore, propose a DL model for the estimation of, (i) COVID-19 lesions in computed tomography (CT) scans and (ii) combining the covariates of PD, COVID-19 lesions, office and laboratory arterial atherosclerotic image-based biomarkers, and medicine usage for the PD patients for the design of DL point-based models for CVD/stroke risk stratification. Results: We validated the feasibility of CVD/stroke risk stratification in PD patients in the presence of a COVID-19 environment and this was also verified. DL architectures like long short-term memory (LSTM), and recurrent neural network (RNN) were studied for CVD/stroke risk stratification showing powerful designs. Lastly, we examined the artificial intelligence bias and provided recommendations for early detection of CVD/stroke in PD patients in the presence of COVID-19. Conclusion: The DL is a very powerful tool for predicting CVD/stroke risk in PD patients affected by COVID-19.

Stereotactic radiosurgery for ruptured versus unruptured intracranial arteriovenous malformations

Background:

There are a limited data examining the effects of prior hemorrhage on outcomes after stereotactic radiosurgery (SRS). The goal of this study was to identify risk factors for arteriovenous malformation (AVM) rupture and compare outcomes, including post-SRS hemorrhage, between patients presenting with ruptured and unruptured AVMs.

Methods:

A retrospective review of consecutive patients undergoing SRS for intracranial AVMs between 2009 and 2019 at our institution was conducted. Chi-square and multivariable logistic regression analyses were utilized to identify patient and AVM factors associated with AVM rupture at presentation and outcomes after SRS including the development of recurrent hemorrhage in both ruptured and unruptured groups.

Results:

Of 210 consecutive patients with intracranial AVMs treated with SRS, 73 patients (34.8%) presented with AVM rupture. Factors associated with AVM rupture included smaller AVM diameter, deep venous drainage, cerebellar location, and the presence of intranidal aneurysms (P < 0.05). In 188 patients with adequate follow-up time (mean 42.7 months), the overall post-SRS hemorrhage rate was 8.5% and was not significantly different between ruptured and unruptured groups (10.3 vs. 7.5%, P = 0.51). There were no significant differences in obliteration rate, time to obliteration, or adverse effects requiring surgery or steroids between unruptured and ruptured groups.

Conclusion:

Smaller AVM size, deep venous drainage, and associated intranidal aneurysms were associated with rupture at presentation. AVM rupture at presentation was not associated with an increased risk of recurrent hemorrhage or other complication after SRS when compared to unruptured AVM presentation. Obliteration rates were similar between ruptured and unruptured groups.

Comparing hematoma characteristics in primary intracerebral hemorrhage versus intracerebral hemorrhage caused by structural vascular lesions

Intracerebral hemorrhage (ICH) caused by structural vascular lesions is associated with better outcomes than primary ICH, but this relationship is poorly understood. We tested the hypothesis that ICH from a vascular lesion has more benign hematoma characteristics compared to primary ICH. We performed a retrospective study using data from our medical center. The SMASH-U criteria were used to adjudicate the etiology of ICH. The co-primary outcomes were admission parenchymal hematoma volume and hematoma expansion at 24 h. Linear and logistic regression analyses were performed to test associations. A total of 231 patients were included of whom 42 (18%) had a vascular lesion. Compared to primary ICH patients, those with structural vascular lesions were younger (49 vs. 68 years, p < 0.001), less likely to have hypertension (29% vs. 74%, p < 0.001), had lower mean admission systolic blood pressure (140 ± 23 vs. 164 ± 35, p < 0.001), less frequently had IVH (26% vs. 44%, p = 0.03), and had mostly lobar or infratentorial hemorrhages. The median admission hematoma volume was smaller with vascular lesions (5.9 vs. 9.7 mL, p = 0.01). In regression models, ICH from a vascular lesion was associated with smaller admission hematoma volume (beta, -0.67, 95% CI, -1.29 to -0.05, p = 0.03), but no association with hematoma expansion was detected when assessed as a continuous (OR, 0.93; 95% CI, -4.46 to 6.30, p = 0.73) or dichotomous exposure (OR, 1.86; 95% CI, 0.40 to 8.51, p = 0.42). In a single-center cohort, patients with ICH from vascular lesions had smaller hematoma volumes than patients with primary ICH.

Cardiovascular/Stroke Risk Stratification in Parkinson's Disease Patients Using Atherosclerosis Pathway and Artificial Intelligence Paradigm: A Systematic Review

Parkinson’s disease (PD) is a severe, incurable, and costly condition leading to heart failure. The link between PD and cardiovascular disease (CVD) is not available, leading to controversies and poor prognosis. Artificial Intelligence (AI) has already shown promise for CVD/stroke risk stratification. However, due to a lack of sample size, comorbidity, insufficient validation, clinical examination, and a lack of big data configuration, there have been no well-explained bias-free AI investigations to establish the CVD/Stroke risk stratification in the PD framework. The study has two objectives: (i) to establish a solid link between PD and CVD/stroke; and (ii) to use the AI paradigm to examine a well-defined CVD/stroke risk stratification in the PD framework. The PRISMA search strategy selected 223 studies for CVD/stroke risk, of which 54 and 44 studies were related to the link between PD-CVD, and PD-stroke, respectively, 59 studies for joint PD-CVD-Stroke framework, and 66 studies were only for the early PD diagnosis without CVD/stroke link. Sequential biological links were used for establishing the hypothesis. For AI design, PD risk factors as covariates along with CVD/stroke as the gold standard were used for predicting the CVD/stroke risk. The most fundamental cause of CVD/stroke damage due to PD is cardiac autonomic dysfunction due to neurodegeneration that leads to heart failure and its edema, and this validated our hypothesis. Finally, we present the novel AI solutions for CVD/stroke risk prediction in the PD framework. The study also recommends strategies for removing the bias in AI for CVD/stroke risk prediction using the PD framework.

Hybrid operation for arteriovenous malformations with associated multiple intracranial aneurysms and subarachnoid hemorrhage: Case report

RATIONALE

The hybrid surgical concept for the treatment of brain arteriovenous malformations (AVMs) with associated intracranial aneurysms (IAs) is still not widely practiced. Concomitant occurrence of AVMs with IAs is common. Subarachnoid hemorrhage (SAH) as a result of AVM or IA rupture is often associated with these dual pathological phenomena. We present a case of concomitant occurrence of AVMs and IAs that was successfully treated using the hybrid operation concept.

PATIENT CONCERNS

A 62-year-old man presented with sudden onset of severe headache, dizziness, nausea, and vomiting for 4 hours.

DIAGNOSIS

Computed tomography revealed SAH and a hematoma in the right frontal lobe. A computed tomographic angiogram also revealed a right frontal AVM with 3 IAs.

INTERVENTIONS

We used a hybrid operating room to successfully treat both AVMs and IAs.

OUTCOMES

Two years of follow-up showed that the patients were well and performed their daily duties.

LESSONS

The hybrid operating room is an innovative, safe, and effective method for the treatment of AVMs with associated IAs, particularly high-grade AVMs and IAs with hemorrhage or SAH. Patients with concomitant AVMs and IAs have the highest chance of hemorrhage compared with those with AVM or IAs alone.

Cerebral Arteriovenous Malformation Deep Draining Veins Not Observed on Preoperative Angiography Identified on Postoperative Angiography

Postoperative digital subtraction angiography (DSA) is the gold standard for establishing a cure of an arteriovenous malformation (AVM) after treatment. The incidence of residual AVM identified on postoperative DSA ranges from 1.8 to 11%. Although this is important for finalizing the treatment of AVMs, postoperative DSA rarely shows new findings that were not previously identified on preoperative imaging. We present a unique case where we identified residual AVM nidus on immediate postoperative DSA that drained into two deep veins that were not evident on preoperative DSA and increased the AVM grade from Spetzler-Martin grade II to III. To our knowledge, this finding has not been previously reported in the literature. We resected the residual AVM nidus identified on postoperative DSA, leading to an angiographic cure. The patient demonstrated a postoperative right-sided supplementary motor area syndrome that resolved over time with therapy. She made a complete functional recovery by her one-month follow-up appointment.

Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment

Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.

Retrospective Study and Outcome Predictor after Microsurgical Resection of Cerebral Arteriovenous Malformations in Nepal

Objective:

The purpose of this study is to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (bAVMs). The relation of outcome using modified Ranklin Scale (mRS) at time of discharge, early and last follow ups with respect to various factors.

Materials and Methods:

Demographic data, arteriovenous malformation characteristics, and treatment outcomes were evaluated in 43 bAVMs treated with microsurgery between 2009 and 2019. For this series, 43 patients were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades (SMG) I/II, III, IV/V and III–V were performed. The mRS was used to assess functional outcomes.

Results:

Overall, mean age at diagnosis was 33 years (standard deviation = 19). Transient deficit, mRS deterioration and impaired functional outcome occurred less frequently in SMG I–II patients compared with Grade III–V patients combined (29% vs. 32% respectively, P = 0.00). All patients with SMG Grade I, Supplemented SMG Grade 2, 3, 4 and 6 had a mRS score of 2 or less at the last follow-up. Age was the only significant predictor of overall outcome after bAVM surgery on Chi-square test (P = 0.046), i.e: all patients <20 years had mRS score of 2 or less on last follow-up. Unfavorable outcome (mRS score of 3 or more than 3) level increased with higher grades in SMG on long term follow-up.

Conclusion:

The results of our case series of bAVM with SMG Grade I and Suplemented Grade 2, 3, 4 and even higher grade i.e., 6 can have excellent overall outcome after microsurgical resection. Association of factors which increases the grading system of bAVM like eloquence, deep venous drainage and increasing sizes did not correlate with the predicted unfavorable outcomes, whereas age of patients was a predictor of overall outcome. Although the small sample size of this study is a limitation, age of patient plays important role on the overall outcome.

External Validation of the R2eD AVM Score to Predict the Likelihood of Rupture Presentation of Brain Arteriovenous Malformations

BACKGROUND

The R2eD AVM scoring system has been recently proposed to predict the risk of hemorrhagic presentation of brain arteriovenous malformations (AVMs).

OBJECTIVE

To perform the first external validation of this R2eD AVM score.

METHODS

Over a retrospective 10-yr period from 2009 to 2019, 122 patients with brain AVMs fit the inclusion criteria. All components required to calculate the R2eD AVM score had to be available. Patient demographics and score calculations were recorded, as well as the circumstances of their presentation. Multivariable analysis was performed to assess predictors of rupture in the study cohort. Next, area under the receiver operating characteristics and linear-by-linear association were employed to assess the effectiveness of the models.

RESULTS

The mean age of the entire cohort was 45.2 yr, and 8% of patients were nonwhite. A total of 48 (39.3%) patients presented with AVM rupture. In univariable analysis, all 5 categories demonstrated P < .15 association with rupture risk. In multivariable analysis, race (nonwhite), size <3 cm, and exclusive deep venous drainage remained in the model with an area under the curve (AUC) of 0.677. The utilization of the R2eD AVM score yielded an AUC of 0.711.

CONCLUSION

Even though mitigated by sample size, this study demonstrated acceptable external validity of the R2eD AVM score.

Systematic review of brain arteriovenous malformation grading systems evaluating microsurgical treatment recommendation

When evaluating brain arteriovenous malformations (bAVMs) for microsurgical resection, the natural history of bAVM rupture must be balanced against the perioperative risks. It is therefore adamant to have a reliable surgical grading system, balancing these important factors. This study systematically reviews the literature in order to identify and assess the quality of grading systems with regard to microsurgical bAVM treatment. A systematic literature review was performed to provide an overview of all available bAVM grading systems relevant for microsurgical treatment evaluation and to assess the most comprehensive grading system specifically for each subgroup of bAVM (i.e., unruptured, ruptured, and posterior fossa). Screening of 865 papers revealed thirteen grading systems for bAVM microsurgical risk stratification. Among them, two systems were specifically developed for ruptured bAVM and one specifically for posterior fossa bAVM. With one system being fundamentally different for supratentorial bAVM, the remaining nine systems used the same parameters: “size,” “eloquence,” “venous drainage,” “arterial feeders,” “age,” “nidus compactness,” and “hemorrhagic presentation”. This study provides a comprehensive overview of all available bAVM grading systems relevant for surgical risk stratification. Furthermore, in the absence of a universal system appropriate to score all bAVMs, a workflow for selection of the best applicable scoring system in accordance with bAVM subgroups is presented.

The Ruptured Arteriovenous Malformation Grading Scale (RAGS): An Extension of the Hunt and Hess Scale to Predict Clinical Outcome for Patients With Ruptured Brain Arteriovenous Malformations

BACKGROUND

Arteriovenous malformation (AVM) rupture is highly morbid. Outcomes after AVM rupture differ from other types of brain hemorrhage. There are no specific widely used grading systems designed to predict clinical outcome after AVM rupture.

OBJECTIVE

To develop an all-comers scoring system to grade patients with AVM rupture and predict clinical outcome more accurately than grading systems currently in use.

METHODS

We retrospectively reviewed patients who presented to our institution with a ruptured AVM. Using change in modified Rankin Score (mRS) as our response variable, we generated an ordinal logistic regression model to test for significant predictor variables. The full model was sequentially condensed until the simplest model with the highest area under the receiver operating curve (AUROC) was achieved.

RESULTS

A total of 115 patients who presented with ruptured AVMs were included in the study, with a mean follow-up time of 4 yr. The Ruptured AVM Grading Scale (RAGS) consists of the Hunt and Hess (HH) score (1-5), patient age (<35 = 0, 35-70 = 1, and >70 = 2), deep venous drainage (1), and eloquence (1). The RAGS score outperformed other neurosurgical grading scales in predicting change in mRS, with an AUROC greater than 0.80 across all follow-up periods.

CONCLUSION

The RAGS score is a simple extension of the HH scale that predicts clinical outcome after AVM rupture more accurately than other grading systems.

"And do no harm": Complications in interventional neuroradiology

Complications are an unfortunate reality in the field of interventional neuroradiology. While complications cannot be eliminated entirely, their occurrence and severity can be mitigated by the competency achieved through training, knowledge of cerebrovascular anatomy and pathology, and well-conceived and executed plans crafted in conjunction with a multidisciplinary team. Frequent communication among the team throughout the entire process of care is vital. In the ensuing chapter, an overview is provided of the most common complication types-nontarget embolization and hemorrhage-followed by practical considerations for their management. Finally, the chapter concludes with a brief consideration of the emotional management for the patient, their loved ones, and the involved practitioners.

Radiosurgery for unruptured brain arteriovenous malformations in the pre-ARUBA era: long-term obliteration rate, risk of hemorrhage and functional outcomes

The management of non-hemorrhagic arteriovenous malformations (AVMs) remains a subject of debate, even more since the ARUBA trial. Here, we report the obliteration rate, the risk of hemorrhage and the functional outcomes after Gamma Knife radiosurgery (GKRS) as first-line treatment for non-hemorrhagic AVMs treated before the ARUBA publication, in a reference university center with multimodal AVM treatments available. We retrospectively analyzed data from a continuous series of 172 patients harboring unruptured AVMs treated by GKRS as first-line treatment in our Lille University Hospital, France, between April 2004 and December 2013. The primary outcome was obliteration rate. Secondary outcomes were the hemorrhage rate, the modified Rankin Scale (mRS), morbidity and epilepsy control at last follow-up. The minimal follow-up period was of 3 years. Median age at presentation was 40 years (IQR 28; 51). Median follow-up was 8.8 years (IQR 6.8; 11.3). Median target volume was 1.9 cm³ (IQR 0.8–3.3 cm³), median Spetzler-Martin grade: 2 (IQR 1–2), median Pollock-Flickinger score: 1.07 (IQR 0.82–2.94), median Virginia score: 1 (IQR 1–2). Median treatment dose was 24 Gy at 50% isodose line. Twenty-three patients underwent a second GKRS after a median time of 58 months after first GKRS. The overall obliteration rate was of 76%, based primarily on cerebral angiography and/or rarely only upon MRI. Hemorrhage during the post-treatment follow-up was reported in 18 (10%) patients (annual risk of 1.1%). Transient post-GKRS morbidity was reported in 14 cases (8%) and persistent neurological deficit in 8 (4.6%) of patients. At last follow-up, 86% of patients had a mRS ≤ 1. Concerning patients with pretherapeutic epilepsy, 84.6% of them were seizure-free at last follow-up. GKRS as first-line therapeutic option for unruptured cerebral AVMs achieves high obliteration rates (76%) while maintaining a high-level patient’s autonomy. All hemorrhagic events occurred during the first 4 years after the initial GKRS. In cases with epilepsy, there was 84.6% seizure free at last follow-up. Permanent morbidity was reported in only 4.6%.

Arteriovenous malformation presenting as traumatic subdural hematoma: A case report

Background:

Brain arteriovenous malformations (AVMs) are congenital aberrant connections between afferent arteries and draining veins with no intervening capillary bed or neural parenchyma. Other than seizures, the most common initial presentation of AVM is hemorrhage, which is typically intraparenchymal, subarachnoid, or intraventricular, and very rarely subdural.

Case Description:

This patient is a 66-year-old male with a history of atrial fibrillation, chronically anticoagulated with apixaban, who presented through emergency services after a fall. On presentation, computed tomography (CT) of the head showed a small, 6 mm right subdural hematoma, and the patient was neurologically intact. The hematoma was evacuated by burr hole craniotomy and placement of a subdural drain 12 days after the initial presentation due to worsening headaches and further hematoma expansion. Two weeks postevacuation, the patient was readmitted for seizures, and at this time, CT angiography showed no intracranial vascular lesion. Approximately 1 month later, the patient was readmitted for decreased responsiveness, and CT head at this time found right frontal intraparenchymal hemorrhage. On subsequent catheter angiography, the right frontal AVM was discovered. It was treated with preoperative embolization followed by surgical resection. Postoperatively, the patient followed commands and tracked with his eyes. There was spontaneous antigravity movement of the right upper extremity, but still no movement of the left upper or bilateral lower extremities.

Conclusion:

This case emphasizes the importance of maintaining a high index of suspicion for underlying vascular lesions when evaluating intracranial bleeding, even in the setting of traumatic history, particularly in cases of hematoma expansion.

Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial

BACKGROUND

In A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA), randomisation was halted at a mean follow-up of 33·3 months after a prespecified interim analysis showed that medical management alone was superior to the combination of medical management and interventional therapy in preventing symptomatic stroke or death. We aimed to study whether these differences persisted through 5-years' follow-up.

METHODS

ARUBA was a non-blinded, randomised trial done at 39 clinical centres in nine countries. Adults (age ≥18 years) diagnosed with an unruptured brain arteriovenous malformation, who had never undergone interventional therapy, and were considered by participating clinical centres to be suitable for intervention to eradicate the lesion, were eligible for inclusion. Patients were randomly assigned (1:1) by a web-based data collection system, stratified by clinical centre in a random permuted block design with block sizes of two, four, and six, to medical management alone or with interventional therapy (neurosurgery, embolisation, or stereotactic radiotherapy, alone or in any combination, sequence, or number). Although patients and investigators at a given centre were not masked to treatment assignment, investigators at other centres and those in the clinical coordinating centre were not informed of assignment or outcomes at any of the centres. The primary outcome was time to death or symptomatic stroke confirmed by imaging, assessed by a neurologist at each centre not involved in the management of participants' care, and monitored by an independent committee using an adaptive approach with interim analyses. Enrolment began on April 4, 2007, and was halted on April 15, 2013, after which follow-up continued until July 15, 2015. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00389181.

FINDINGS

Of 1740 patients screened, 226 were randomly assigned to medical management alone (n=110) or medical management plus interventional therapy (n=116). During a mean follow-up of 50·4 months (SD 22·9), the incidence of death or symptomatic stroke was lower with medical management alone (15 of 110, 3·39 per 100 patient-years) than with medical management with interventional therapy (41 of 116, 12·32 per 100 patient-years; hazard ratio 0·31, 95% CI 0·17 to 0·56). Two patients in the medical management group and four in the interventional therapy group (two attributed to intervention) died during follow-up. Adverse events were observed less often in patients allocated to medical management compared with interventional therapy (283 vs 369; 58·97 vs 78·73 per 100 patient-years; risk difference -19·76, 95% CI -30·33 to -9·19).

INTERPRETATION

After extended follow-up, ARUBA showed that medical management alone remained superior to interventional therapy for the prevention of death or symptomatic stroke in patients with an unruptured brain arteriovenous malformation. The data concerning the disparity in outcomes should affect standard specialist practice and the information presented to patients. The even longer-term risks and differences between the two therapeutic approaches remains uncertain.

FUNDING

National Institute of Neurological Disorders and Stroke for the randomisation phase and Vital Projects Fund for the follow-up phase.

Clinical outcome following cerebral AVM hemorrhage

BACKGROUND

A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage.

METHODS

Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results.

RESULTS

No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies.

CONCLUSIONS

The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.

Outcome Comparison Between Surgically Treated Brain Arteriovenous Malformation Hemorrhage and Spontaneous Intracerebral Hemorrhage

BACKGROUND

Case fatality and poor outcome rates are different between brain arteriovenous malformation-associated intracerebral hemorrhage (bAVM-ICH) and spontaneous intracerebral hemorrhage (SICH). These outcome rates, however, have never been compared in patients who need neurosurgical evacuation of the intracerebral hemorrhage (ICH).

OBJECTIVE

To compare the short- and long-term functional outcome between surgically treated patients with bAVM-ICH and SICH.

METHODS

We collected data from surgically treated ICH patients at the Department of Neurosurgery, University Hospital Zurich, from January 2015 to July 2018. We performed logistic regression analysis to compare the functional outcome between groups, adjusting for demographics, admission characteristics, and stroke risk factors.

RESULTS

A total of 26 bAVM-ICH and 115 SICH patients were included in the final analysis. Patients with bAVM-ICH were younger and less likely to have hypertension without significant differences in ICH volume, hematoma location, intraventricular hemorrhage, and other stroke risk factors. A significantly better functional outcome rate was seen in bAVM-ICH patients at short- and long-term follow-up. These differences remained significant after adjusting for confounders.

CONCLUSIONS

patients with a bAVM who need surgical evacuation of an ICH have a more favorable outcome than surgically treated patients with spontaneous ICH, even after correction for confounding factors, such as younger age and less premorbid hypertension.

Intraventricular haemorrhage due to re-ruptured arteriovenous malformation cleared with tissue plasminogen activator administered through a pre-existing ventriculoperitoneal shunt

In the context in intraventricular haemorrhage (IVH), intrathecal thrombolytic agents administered in conjunction with extraventricular drainage have been demonstrated to clear larger volumes of blood and reduce mortality rates. However, patients with arteriovenous malformations (AVM) have been mostly excluded from clinical trials. We describe a patient with hydrocephalus secondary to a ruptured AVM who was treated via external ventriculostomy, which was subsequently converted to a ventriculoperitoneal shunt (VPS). Eight months later, the AVM re-ruptured, causing IVH and rendering the patient comatose. Taking into consideration the patient's poor outlook, a single dose of intraventricular tissue plasminogen activator (t-PA) was administered through the shunt reservoir. The shunt maintained its function and the patient's condition ultimately improved. This impressive case demonstrates the utility of t-PA administered through an existing VPS in the setting of IVH due to ruptured AVM, highlighting its lifesaving potential in the appropriate patient and overall decrease in the cost of care by mitigating the need for shunt revision.

Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study

OBJECTIVE

Arteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects.

METHODS

The authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome.

RESULTS

The study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044).

CONCLUSIONS

SRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.

Differences in bleeding patterns and outcome after intracerebral hemorrhage due to vascular malformations

BACKGROUND

Atypical intracerebral hemorrhage is a common form of primary manifestation of vascular malformations.

OBJECTIVE

The aim of the present study is to determine clues to the cause of bleeding according to hemorrhage pattern (lobar, basal ganglia, infratentorial).

METHODS

We retrospectively evaluated 343 consecutive neurosurgical patients with intracerebral hemorrhage (ICH), who were admitted to our neurosurgical department between 2006 and 2016. The study cohort includes only neurosurgical patients. Patients who underwent treatment by neurologists are not represented in this study. We assessed location of hemorrhage, hematoma volumes to rule out differences and predicitve variables for final outcome.

RESULTS

In 171 cases (49.9%) vascular malformations, such as arteriovenous malformations (AVMs), cavernomas, dural fistulas and aneurysms were the cause of bleeding. 172 (50.1%) patients suffered from an intracerebral hemorrhage due to amyloid angiopathy or long standing hypertension. In patients with infratentorial hemorrhage a malformation was more frequently detected as in patients with supratentorial hemorrhage (36% vs. 16%, OR 2.9 [1.8;4.9], p<0.001). Among the malformations AVMs were most common (81%). Hematoma expansion was smaller in vascular malformation than non-malformation caused bleeding (24.1 cm3 vs. 64.8 cm3, OR 0.5 [0.4;0.7], p < 0.001,). In 6 (2.1%) cases diagnosis remained unclear. Final outcome was more favorable in patients with vascular malformations (63% vs. 12%, OR 12.8 [4.5;36.2], p<0.001).

CONCLUSION

Localization and bleeding patterns are predictive factors for origin of the hemorrhage. These predictive factors should quickly lead to appropriate vascular diagnostic measures. However, due to the inclusion criteria the validity of the study is limited and multicentre studies with further testing in general ICH patients are required.

Acute Subdural Hematomas in Ruptured Brain Arteriovenous Malformations: Association with Distal Flow-Related Aneurysms

PURPOSE

Non-traumatic acute subdural hematomas (SDH) are rare and have seldom been reported in ruptured brain arteriovenous malformations (BAVM). The aim of this study was to report the frequency of acute SDH in BAVM-related hemorrhage and to determine the relationship of SDHs with BAVM angioarchitectural features.

METHODS

This was a retrospective monocentric study of patients admitted for BAVM rupture between 2003 and 2017. Patients with rupture complicating or closely following partial embolization procedures were excluded. Univariate followed by multivariate logistic regression analysis was used to determine factors significantly and independently associated with SDHs and distal flow-related aneurysms.

RESULTS

A total of 181 patients with 188 BAVM ruptures admitted during the study period were included, eleven cases of acute SDH were identified (6%) and 2 cases of isolated SDH were found. The presence of a distal flow-related aneurysm was the only feature independently and significantly associated with SDH (odds ratio [OR] 8.1, 95% confidence interval, CI 1.9-34.5, P = 0.003). Distal flow-related aneurysms were associated with proximal flow-related aneurysms (OR 28, 95%CI 4.9-163.8, P < 0.001), were more frequent in infratentorial BAVMs (OR 3.7, 95%CI 1.3-10.2, P = 0.01) and more often found in cases of acute SDH (OR 16.9, 95%CI 3.6-79.6, P < 0.001) and subarachnoid hemorrhage (SAH) (OR 4.5, 95%CI 1.7-12.2, P = 0.003).

CONCLUSION

Ruptured BAVMs can rarely present with acute SDH and SDH in ruptured BAVMs are often associated with distal flow-related aneurysms. This finding may impact acute management of ruptured BAVMs with SDH by eliciting an emergent and thorough imaging work-up to identify distal flow-related aneurysm(s), in turn leading to treatment.

The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis

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.

Evaluation of Angioarchitectural Features of Unruptured Brain Arteriovenous Malformation by Susceptibility Weighted Imaging

OBJECTIVES

A precise assessment of angioarchitectural characteristics using noninvasive imaging is helpful for serial follow-up and weighting risk of natural history in unruptured brain arteriovenous malformation (bAVM). This study aimed to test the hypothesis that susceptibility weighted imaging (SWI) would provide an accurate evaluation of angioarchitectural features of unruptured bAVM.

METHODS

A total of 81 consecutive patients with unruptured bAVM were examined. Image quality of SWI for the assessment of bAVM angioarchitectural features was determined by a 5-point scale. The accuracy of SWI for detection of angioarchitectural features was evaluated using digital subtraction angiography as a standard reference and further compared among unruptured bAVMs with or without silent intralesional microhemorrhage on SWI to examine the potential confounding effect of microhemorrhage on image analysis.

RESULTS

All lesions were identified on SWI. Image quality of SWI was judged to be at least adequate for diagnosis (range, 3-5) in all patients by both readers. Using digital subtraction angiography as a reference standard, the area under the receiver operating curve of detection of deep or posterior fossa location, exclusively deep venous drainage, venous ectasia, venous varices, and the presence of associated aneurysm on SWI was 1, 0.93, 0.94, 0.95, and 0.83, respectively. Silent intralesional microhemorrhage were detected in 39 patients (48.15%) on SWI and no significant difference (P > 0.05) was found in angioarchitectural features between patients with and without silent microhemorrhage.

CONCLUSIONS

SWI might be a noninvasive alternative technique for angiography in the angioarchitectural assessment of unruptured bAVM.

Intraventricular hemorrhage related to AVM rupture: Description, outcomes and impact of intraventricular fibrinolysis

OBJECTIVES

Arteriovenous malformation (AVM) rupture could lead to intraventricular hemorrhage (IVH), a particularly severe form of intracranial bleeding. The epidemiology, presentation, management and outcomes of IVH related to AVM rupture have not been clearly addressed yet. The aim of the present study was to investigate the characteristics of IVH related to AVM rupture, with particular attention paid to functional outcomes and to the impact of intraventricular fibrinolysis (IVF).

PATIENTS AND METHODS

Between 2011 and 2015, all patients suffering from IVH admitted in two tertiary neurosurgical centers were included in a prospective register. Patient with IVH related to AVM rupture were identified (n=29) and their data retrospectively collected. Particular attention was paid on patients who received IVF. We also compared them to 29 apparied aneurysmal IVH.

RESULTS

IVH related to AVM rupture often occurred in young patients. In most cases, intracerebral hemorrhage was associated to IVH. 17% of the patients died, and functional outcome at 6 months was similar to those with aneurysmal IVH. Interestingly, 5 patients received IVF and none experienced any rebleeding.

CONCLUSION

IVH related to AVM rupture is a severe form of hemorrhagic stroke, with a poor neurologic prognosis. IVF seems to be safe and may be considered in this particular form of IVH.

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

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

Early Rebleeding after Brain Arteriovenous Malformation Rupture, Clinical Impact and Predictive Factors: A Monocentric Retrospective Cohort Study

Background: Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. This study aimed to identify individual predictive factors of early rebleeding after BAVM rupture and determine its impact on prognosis. Methods: Early rebleeding was defined as a spontaneous intracranial hemorrhage within 30 days of BAVM rupture in patients with nonobliterated BAVMs. One hundred fifty one patients with 158 BAVM hemorrhagic events admitted to a tertiary care center during 14 years were included. Univariate followed by multivariate logistic regression was performed to assess the impact of early rebleeding on in-hospital mortality and modified Rankin Scale (mRS) score beyond 3 months and to identify independent predictors of early rebleeding. Results: Eight early rebleeding events were observed, 6 of which occurred during the first 7 days. Early rebleeding was independently and significantly associated with poor outcome (mRS ≥3 beyond 3 months, p = 0.004) but not with in-hospital mortality (p = 0.9). Distal flow-related aneurysms (p = 0.009) and altered consciousness with a Glasgow coma scale score of 3 (p = 0.01) were independently associated with early rebleeding. Conclusions: Early rebleeding is a severe complication that can occur after BAVM-related hemorrhage. Distal flow-related aneurysms and initial altered consciousness are associated with early rebleeding.

Decompressive craniectomy for intracerebral haematoma: the influence of additional haematoma evacuation

Intracerebral haemorrhage (ICH) may lead to intractable elevation of intracranial pressure (ICP), which may lead to decompressive craniectomy (DC). In this setting, surgical evacuation of ICH is controversially discussed. We therefore analysed radiological and clinical parameters to investigate the influence of additional haematoma evacuation to DC in patients with ICH. Forty-four patients suffering from spontaneous, hypertensive ICH between August 2007 and February 2016 underwent DC with and without ICH evacuation at the author's institution. Patients were stratified into two groups (DC without ICH evacuation versus DC with ICH evacuation). Patient characteristics, clinical and radiological findings were assessed and retrospectively analysed. Fifteen (34%) patients underwent DC with additional ICH evacuation and 29 (66%) underwent DC without ICH evacuation. Mean ICH volume was 60 ± 38 ml with no significant difference between both groups (p = 0.8). Midline shift (MLS) reduction after DC did not significantly differ between both groups (p = 0.4). Overall, 13 patients (30%) achieved a favourable outcome. DC can be performed in cases of spontaneous supratentorial ICH and pathological elevated ICP despite best medical treatment. However, additional ICH evacuation does not seem to be beneficial according to the present study and may therefore be omitted.

Functional impairments for outcomes in a randomized trial of unruptured brain AVMs

OBJECTIVE

To investigate the effects of medical vs interventional management on functional outcome in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA).

METHODS

We used the initial results of a nonblinded, randomized, controlled, parallel-group trial involving adults ≥18 years of age with an unruptured brain arteriovenous malformation (AVM) to compare the effects of medical management (MM) with or without interventional therapy (IT) on functional impairment, defined by a primary outcome of death or symptomatic stroke causing modified Rankin Scale (mRS) score ≥2. ARUBA closed recruitment on April 15, 2013.

RESULTS

After a median of 33.3 months of follow-up (interquartile range 16.3-49.8 months), of the 223 enrolled in the trial, those in the MM arm were less likely to experience primary outcomes with an mRS score ≥2 than those who underwent IT. The results applied for both those as randomized (MM n = 109 vs IT n = 114) (hazard ratio [HR] 0.25, 95% confidence interval [CI] 0.11-0.57, p = 0.001) and as treated (MM n = 125 vs IT n = 98) (HR 0.10, 95% CI 0.04-0.28, p < 0.001). Functional impairment for the outcomes showed no significant difference by Spetzler-Martin grade for MM but was more frequent with increasing grades for IT (p < 0.001).

CONCLUSION

Death or stroke with functional impairment in ARUBA after a median follow-up of 33 months was significantly lower for those in the MM arm both as randomized and as treated compared with those with IT. Functional severity of outcomes was lower in the MM arm, regardless of Spetzler-Martin grades.

CLINICALTRIALSGOV IDENTIFIER

NCT00389181.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for adults with unruptured brain AVMs, interventional management compared to MM increases the risk of disability and death over ≈3 years.

Stereotactic Radiosurgery for Brainstem Arteriovenous Malformations: A Multicenter Study

BACKGROUND

The management of brainstem arteriovenous malformations (bAVMs) is a formidable challenge. bAVMs harbor higher morbidity and mortality compared to other locations.

OBJECTIVE

To review the outcomes following stereotactic radiosurgery (SRS) of bAVMs in a multicenter study.

METHODS

Six medical centers contributed data from 205 patients through the International Gamma Knife Research Foundation. Median age was 32 yr (6-81). Median nidus volume was 1.4 mL (0.1-69 mL). Favorable outcome (FO) was defined as AVM obliteration and no post-treatment hemorrhage or permanent symptomatic radiation-induced complications.

RESULTS

Overall obliteration was reported in 65.4% (n = 134) at a mean follow-up of 69 mo. Obliteration was angiographically proven in 53.2% (n = 109) and on MRA in 12.2% (n = 25). Actuarial rate of obliteration at 2, 3, 5, 7, and 10 yr after SRS was 24.5%, 43.3%, 62.3%, 73%, and 81.8% respectively. Patients treated with a margin dose &gt;20 Gy were more likely to achieve obliteration (P = .001). Obliteration occurred earlier in patients who received a higher prescribed margin dose (P = .05) and maximum dose (P = .041). Post-SRS hemorrhage occurred in 8.8% (n = 18). Annual postgamma knife latency period hemorrhage was 1.5%. Radiation-induced complications were radiologically evident in 35.6% (n = 73), symptomatic in 14.6% (n = 30), and permanent in 14.6% (n = 30, which included long-tract signs and new cranial nerve deficits). FO was achieved in 64.4% (n = 132). Predictors of an FO were a higher Virginia radiosurgery AVM scale score (P = .003), prior hemorrhage (P = .045), and a lower prescribed maximum dose (P = .006).

CONCLUSION

SRS for bAVMs results in obliteration and avoids permanent complications in the majority of patients.

Early outcomes and periprocedural complications of transarterial embolization of brain arteriovenous malformations with Onyx®

BACKGROUND

Brain arteriovenous malformation (BAVM) is a rare pathology diagnosed mostly in young adults. However, due to its hemorrhagic complications, it constitutes an important clinical problem. Treatment modalities available include endovascular, surgery and radiosurgery. The aim of the study was to assess the efficacy and safety of endovascular treatment of BAVM with Onyx^® by reporting one-center experience.

MATERIAL AND METHODS

Between 2006 and 2013, 54 patients with BAVM were embolized with Onyx. The group consisted of 24 males and 30 females, aged 10 to 65 years (mean 42.6±15.4). Clinical manifestations of BAVMs were: hemorrhage in 27 (50.0%), headaches in 12 (22.2%), seizures in 7 (13.0%) and focal neurologic deficits in 2 (3.7%) patients. Six (11.1%) patients were asymptomatic. A majority of BAVMs were of II and III grade in Spetzler-Martin scale (19 and 22 cases respectively).

RESULTS

A total number of 108 endovascular procedures were performed (mean 2.00±0.98 sessions/patient). Complete obliteration of malformation was achieved in 25 (46.3%) patients, mostly with grade II and III BAVMs. In 29 (53.7%) patients, embolization led to a decrease in size of BAVM that made it feasible for other treatment modality. Morbidity and mortality rates were 5.6% and 1.8% respectively. The rate of hemorrhagic complications was 9.3%.

CONCLUSION

Embolization of BAVM with Onyx^® is an effective and safe method of treatment. However, regarding type and consequences of complications, the technique needs further improvement.

Outcomes after intracerebral hemorrhage from arteriovenous malformations

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Microsurgery for intracranial arteriovenous malformation: Long-term outcomes in 445 patients

BACKGROUND

The management of intracranial arteriovenous malformations(AVMs) poses challenges to the cerebrovascular specialists.

OBJECTIVE

To review the long-term outcomes of intracranial AVMs treated with microsurgical resections.

METHODS

We performed a retrospective review of 445 patients with intracranial AVMs treated in our hospital from January 1st, 2008 to December 31st, 2014. The extracted data included demographic characteristics, clinical presentations, Spetzler-Martin (SM) grades, Supplemented Spetzler-Martin (SM-Supp) Grades, treatment modalities, long-term outcomes, and obliteration rates. Outcome was assessed with a post-operative modified Rankin Scale (mRS) score at the last follow-up visit.

RESULTS

Of the 445 patients treated with microsurgery, 298 (67.0%) patients initially presented with hemorrhage. Based on the SM grading system, the patients were graded as follows: 83(18.6%) Grade I, 156(35.1%) Grade II, 132(29.7%) Grade III, 61(13.7%) Grade IV and 13(2.9%) Grade V. Overall, 344(77.3%) patients had a favorable outcome (mRS score of 0-2). The favorable outcome for Grade I and II were 92.8% and 85.9%, respectively, sharply reducing to 52.5% in patients with Grade IV and 15.4% in patients with Grade V AVMs. 388(87.2%) patients achieved complete obliteration of the AVMs. 63(14.2%) patients experienced recurrent hemorrhage, and the frequency of rehemorrhage was highest in Grade V patients (77.0%), dropping to 3.6% and 3.8% in patients with Grade I and II lesions, respectively. Permanent neurological deficits occurred in 66(14.8%) patients and death in 35(7.9%) patients. There was no difference of AUROC values between SM grading system and SM-supp grading system (0.726 and 0.734, respectively, p = .715).

CONCLUSION

The Spetzler-Martin grading system is a simple and effective method to estimate the risk of surgery and to evaluate the prognosis. Microsurgical resection for AVMs depends on the SM grades, and the morbidity-mortality rate increases with an increasing SM grade.

Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation

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.

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

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

Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort

OBJECTIVE

In this multicenter study, the authors reviewed the results following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs), determined predictors of outcome, and assessed predictive value of commonly used grading scales based upon this large cohort with long-term follow-up.

METHODS

Data from a cohort of 2236 patients undergoing GKRS for cerebral AVMs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and AVM characteristics were assessed to determine predictors of outcome, and commonly used grading scales were assessed.

RESULTS

The mean maximum AVM diameter was 2.3 cm, with a mean volume of 4.3 cm3. A mean margin dose of 20.5 Gy was delivered. Mean follow-up was 7 years (range 1–20 years). Overall obliteration was 64.7%. Post-GRKS hemorrhage occurred in 165 patients (annual risk 1.1%). Radiation-induced imaging changes occurred in 29.2%; 9.7% were symptomatic, and 2.7% had permanent deficits. Favorable outcome was achieved in 60.3% of patients. Patients with prior nidal embolization (OR 2.1, p < 0.001), prior AVM hemorrhage (OR 1.3, p = 0.007), eloquent location (OR 1.3, p = 0.029), higher volume (OR 1.01, p < 0.001), lower margin dose (OR 0.9, p < 0.001), and more isocenters (OR 1.1, p = 0.011) were more likely to have unfavorable outcomes in multivariate analysis. The Spetzler-Martin grade and radiosurgery-based AVM score predicted outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.

CONCLUSIONS

GKRS for cerebral AVMs achieves obliteration and avoids permanent complications in the majority of patients. Patient, AVM, and treatment parameters can be used to predict long-term outcomes following radiosurgery.