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Silva AHD, James G. Natural history and clinical manifestation of Pediatric Brain Arteriovenous Malformations. J Korean Neurosurg Soc 2024; 67:280-288. [PMID: 38720544 PMCID: PMC11079564 DOI: 10.3340/jkns.2024.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024] Open
Abstract
Brain arteriovenous malformations (bAVMs) are aberrant arteriovenous shunts through a vascular nidus with no intervening capillary beds. They are one of the commonest causes of spontaneous intracranial haemorrhage in children and may be associated with significant morbidity and mortality in cases of rupture. Treatment strategies include microsurgical resection, endovascular embolisation, stereotactic radiosurgery, multimodality treatment with a combination thereof, and particularly in high-grade bAVMs, conservative management. Clinicians involved in treating bAVMs need to have familiarity with the natural history pertaining to bAVMs in terms of risk of rupture, risk factors elevating rupture risk as well as understanding the clinical manifestations of bAVMs. This invited review serves to provide a synthesis on natural history and clinical presentation of bAVMs with particular focus in children to inform decision-making pertaining to management.
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Affiliation(s)
- Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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2
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Koester SW, Batista S, Bertani R, Yengo-Kahn A, Roth S, Chitale R, Dewan M. Angiographic factors leading to hemorrhage in AVMs: A systematic review and meta-analysis. Neurosurg Rev 2023; 46:72. [PMID: 36935466 DOI: 10.1007/s10143-023-01971-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/18/2022] [Accepted: 02/27/2023] [Indexed: 03/21/2023]
Abstract
For patients with unruptured intracranial arteriovenous malformations (AVMs), the risk of a hemorrhagic event is approximately 2% to 4% annually. These events have an associated 20-50% morbidity and 10% mortality rate. An understanding of risk factors that predispose these lesions to rupture is important for optimal management. We aimed to pool a large cohort of both ruptured and unruptured AVMs from the literature with the goal of identifying angiographic risk factors that contribute to rupture. A systematic review of the literature was conducted in accordance with the PRISMA guidelines using Pubmed, Embase, Scopus, and Web of Science databases. Studies that presented patient-level data from ruptured AVMs from January 1990 to January 2022 were considered for inclusion. The initial screening of 8,304 papers resulted in a quantitative analysis of 25 papers, which identified six angiographic risk factors for AVM rupture. Characteristics that significantly increase the odds of rupture include the presence of aneurysm (OR = 1.45 [1.19, 1.77], p < 0.001, deep location (OR = 3.08 [2.56, 3.70], p < 0.001), infratentorial location (OR = 2.79 [2.08, 3.75], p < 0.001), exclusive deep venous drainage (OR = 2.50 [1.73, 3.61], p < 0.001), single venous drainage (OR = 2.97 [1.93, 4.56], p < 0.001), and nidus size less than 3 cm (OR = 2.54 [1.41, 4.57], p = 0.002). Although previous literature has provided insight into AVM rupture risk factors, obscurity still exists regarding which risk factors pose the greatest risk. We have identified six major angiographic risk factors (presence of an aneurysm, deep location, infratentorial location, exclusive deep venous drainage, single venous drainage, and nidus size less than 3 cm) that, when identified by a clinician, may help to tailor patient-specific approaches and guide clinical decisions.
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Affiliation(s)
| | - Savio Batista
- Hospital Miguel Couto Neurological Surgery, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Hospital Miguel Couto Neurological Surgery, Rio de Janeiro, Brazil
| | - Aaron Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA
| | - Steven Roth
- Department of Neurosurgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA
| | - Rohan Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA
| | - Michael Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, 1161 21st Ave. So., T4224 Medical Center North, Nashville, TN, 37232-2380, USA.
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3
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Chowdhury SS, See AP, Eriksson LP, Boulouis G, Lehman LL, Hararr DB, Zabih V, Dlamini N, Fox C, Waak M. Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review. Semin Pediatr Neurol 2022; 43:101001. [PMID: 36344021 DOI: 10.1016/j.spen.2022.101001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma >2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).
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Affiliation(s)
| | | | | | | | | | | | - Veda Zabih
- The Hospital for Sick Children, Toronto, Canada
| | | | | | - Michaela Waak
- The University of Queensland, Australia; Children's Health Queensland Hospital, Brisbane, Australia
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4
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2021; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Garzelli L, Shotar E, Blauwblomme T, Sourour N, Alias Q, Stricker S, Mathon B, Kossorotoff M, Gariel F, Boddaert N, Brunelle F, Meyer P, Naggara O, Clarençon F, Boulouis G. Risk Factors for Early Brain AVM Rupture: Cohort Study of Pediatric and Adult Patients. AJNR Am J Neuroradiol 2020; 41:2358-2363. [PMID: 33122204 DOI: 10.3174/ajnr.a6824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Whether architectural characteristics of ruptured brain AVMs vary across the life span is unknown. We aimed to identify angioarchitectural features associated with brain AVMs ruptured early in life. MATERIALS AND METHODS Patients with ruptured brain AVMs referred to 2 distinct academic centers between 2000 and 2018 were pooled and retrospectively analyzed. Imaging was retrospectively reviewed for angioarchitectural characteristics, including nidus size, location, Spetzler-Martin grade, venous drainage, and arterial or nidal aneurysm. Angioarchitecture variations across age groups were analyzed using uni- and multivariable models; then cohorts were pooled and analyzed using Kaplan-Meier and Cox models to determine factors associated with earlier rupture. RESULTS Among 320 included patients, 122 children (mean age, 9.8 ± 3.8 years) and 198 adults (mean age, 43.3 ± 15.7 years) were analyzed. Pediatric brain AVMs were more frequently deeply located (56.3% versus 21.2%, P < .001), with a larger nidus (24.2 versus 18.9 mm, P = .002), were less frequently nidal (15.9% versus 23.5%, P = .03) and arterial aneurysms (2.7% versus 17.9%, P < .001), and had similar drainage patterns or Spetzler-Martin grades. In the fully adjusted Cox model, supratentorial, deep brain AVM locations (adjusted relative risk, 1.19; 95% CI, 1.01-1.41; P = .03 and adjusted relative risk, 1.43; 95% CI, 1.22-1.67; P < .001, respectively) and exclusively deep venous drainage (adjusted relative risk, 1.46, 95% CI, 1.21-1.76; P < .001) were associated with earlier rupture, whereas arterial or nidal aneurysms were associated with rupture later in life. CONCLUSIONS The angioarchitecture of ruptured brain AVMs significantly varies across the life span. These distinct features may help to guide treatment decisions for patients with unruptured AVMs.
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Affiliation(s)
- L Garzelli
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Departments of Neuroradiology (L.G., F.C.)
| | - E Shotar
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - T Blauwblomme
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke.,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - N Sourour
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - Q Alias
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.)
| | - S Stricker
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke
| | - B Mathon
- Neurosurgery (B.M.), Sorbonne University, Paris, France.,Neurosurgery (B.M.), Pitié-Salpêtrière University Hospital, Public Assistance-Paris Hospitals, Paris, France.,Brain and Spine Institute (B.M.), Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1127; Centre National de la Recherche Scientifique, Unité Mixte de Recherche 7225, Paris, France
| | - M Kossorotoff
- Department of Pediatric Neurology (M.K.), French Center for Pediatric Stroke
| | - F Gariel
- Department of Neuroimaging (F.G.), Pellegrin Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - N Boddaert
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Brunelle
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - P Meyer
- Department of Anesthesiology (P.M.), Necker-Enfants Malades University Hospital, Public Assistance-Paris Hospitals, Paris, France
| | - O Naggara
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Clarençon
- Departments of Neuroradiology (L.G., F.C.).,Department of Neuroradiology (E.S., N.S., F.C.)
| | - G Boulouis
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France .,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
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Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2020; 215:472-487. [DOI: 10.2214/ajr.19.22443] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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7
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LoPresti MA, Goethe EA, Lam S. Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy. Childs Nerv Syst 2020; 36:1445-1452. [PMID: 31932976 DOI: 10.1007/s00381-020-04501-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children. METHODS A retrospective chart review was conducted examining patients age 0-18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage. RESULTS Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures. CONCLUSIONS Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
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Affiliation(s)
- Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sandi Lam
- Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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8
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McDowell MM, Agarwal N, Mao G, Johnson S, Kano H, Lunsford LD, Greene S. Long-term outcomes of pediatric arteriovenous malformations: the 30-year Pittsburgh experience. J Neurosurg Pediatr 2020; 26:275-282. [PMID: 32413859 DOI: 10.3171/2020.3.peds19614] [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: 10/22/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The study of pediatric arteriovenous malformations (pAVMs) is complicated by the rarity of the entity. Treatment choice has often been affected by the availability of different modalities and the experience of the providers present. The University of Pittsburgh experience of multimodality treatment of pAVMs is presented. METHODS The authors conducted a retrospective cohort study examining 212 patients with pAVM presenting to the University of Pittsburgh between 1988 and 2018, during which patients had access to surgical, endovascular, and radiosurgical options. Univariate analysis was performed comparing good and poor outcomes. A poor outcome was defined as a modified Rankin Scale (mRS) score of ≥ 3. Multivariate analysis via logistic regression was performed on appropriate variables with a p value of ≤ 0.2. Seventy-five percent of the cohort had at least 3 years of follow-up. RESULTS Five patients (2.4%) did not receive any intervention, 131 (61.8%) had GKRS alone, 14 (6.6%) had craniotomies alone, and 2 (0.9%) had embolization alone. Twenty-two (10.4%) had embolization and Gamma Knife radiosurgery (GKRS); 20 (9.4%) had craniotomies and GKRS; 8 (3.8%) had embolization and craniotomies; and 10 (4.7%) had embolization, craniotomies, and GKRS. Thirty-one patients (14.6%) were found to have poor outcome on follow-up. The multivariate analysis performed in patients with poor outcomes was notable for associations with no treatment (OR 18.9, p = 0.02), hemorrhage requiring craniotomy for decompression alone (OR 6, p = 0.03), preoperative mRS score (OR 2.1, p = 0.004), and Spetzler-Martin score (OR 1.8, p = 0.0005). The mean follow-up was 79.7 ± 62.1 months. The confirmed radiographic obliteration rate was 79.4% and there were 5 recurrences found on average 9.5 years after treatment. CONCLUSIONS High rates of long-term functional independence (mRS score of ≤ 2) can be achieved with comprehensive multimodality treatment of pAVMs. At this center there was no difference in outcome based on treatment choice when accounting for factors such as Spetzler-Martin grade and presenting morbidity. Recurrences are rare but frequently occur years after treatment, emphasizing the need for long-term screening after obliteration.
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Affiliation(s)
- Michael M McDowell
- 1Division of Neurological Surgery, Children's Hospital of Pittsburgh.,2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Nitin Agarwal
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Gordon Mao
- 3Department of Neurological Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Stephen Johnson
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Hideyuki Kano
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Stephanie Greene
- 1Division of Neurological Surgery, Children's Hospital of Pittsburgh.,2Department of Neurological Surgery, University of Pittsburgh Medical Center; and
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9
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Yang WY, Luo CB, Tsuei YS, Guo WY, Wu HM, Chung WY. A single-institution study of predisposing factors of patients with BAVMs to flow-related aneurysm. J Formos Med Assoc 2019; 118:707-712. [DOI: 10.1016/j.jfma.2018.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/11/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022] Open
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10
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Ai X, Ye Z, Xu J, You C, Jiang Y. The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis. J Neurosurg Pediatr 2018; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/06/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs. METHODS The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients. CONCLUSIONS Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation. ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; NOS = Newcastle-Ottawa Scale; OR = odds ratio; SM = Spetzler-Martin.
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Affiliation(s)
| | | | | | | | - Yan Jiang
- 2Nursing Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Sosa F, Bustamante J, Rodríguez F, Argañaraz R, Rubino P, Lambre J. [Foreign accent syndrome after aneurysmal disappearance due to AVM treatment]. Surg Neurol Int 2017; 8:S1-S4. [PMID: 28480115 PMCID: PMC5402325 DOI: 10.4103/2152-7806.203165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/26/2016] [Indexed: 12/04/2022] Open
Abstract
Introducción: Los aneurismas asociados a malformaciones arteriovenosas (MAV) son lesiones vasculares que suelen encontrarse hasta en el 15% de los casos, incrementando el riesgo global de hemorragia. La conducta frente a los aneurismas asociados es dicotómica en la literatura, mientras existen reportes de la desaparición de los mismos luego de la exéresis de la MAV, otros artículos enfatizan su tratamiento precoz. El síndrome del acento extranjero es un raro trastorno neurológico en el que el paciente habla su lengua materna como lo haría una persona extranjera y suena con “acento” extranjero a oídos de los oyentes nativos. Objetivo: Presentar un paciente que desarrolla el síndrome del acento extranjero posterior a la exéresis de una MAV y la evolución de un aneurisma asociado. Presentación de caso: Paciente pediátrico que luego de la exéresis de una MAV fronto-opercular posterior izquierda remite por completo un aneurisma de hiperflujo asociado, presentando en el postquirúrgico el síndrome del acento extranjero. Conclusión: Queda reportado el caso de este raro síndrome y la resolución espontánea de un aneurisma proximal luego de la exéresis de una MAV.
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Affiliation(s)
- Fidel Sosa
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
| | - Jorge Bustamante
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
| | - Facundo Rodríguez
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
| | - Romina Argañaraz
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
| | - Pablo Rubino
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
| | - Jorge Lambre
- Servicio de Neurocirugía, Hospital El Cruce SAMIC, Florencio Varela, Buenos Aires, Argentina
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Arterial aneurysms associated with arteriovenous malformations of the brain: classification, incidence, risk of hemorrhage, and treatment-a systematic review. Acta Neurochir (Wien) 2016; 158:2095-2104. [PMID: 27644700 DOI: 10.1007/s00701-016-2957-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Aneurysms associated with brain arteriovenous malformations (bAVMs) influence the natural history of these lesions and pose important therapeutic challenges. However, the epidemiology, natural history, and appropriate management of the aneurysms associated with bAVMs are not completely understood due to the paucity of large and uniform studies. We performed a systematic review of published series examining the association between aneurysms and bAVMs with the purpose of clarifying the prevalence, risk of hemorrhage, and appropriate management of these lesions. METHOD PRISMA/MOOSE guidelines were followed. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on aneurysms associated with bAVMs. Only studies examining consecutive case series of aneurysms associated with bAVMs were included. From the collected studies, we extracted data regarding prevalence of bAVM-associated aneurysms, risk of aneurysm rupture in relation to bAVM location and aneurysm characteristics, and treatment-related outcomes. RESULTS Our systematic review included 44 articles with a total of 10,093 bAVMs. The proportion of bAVMs with an associated aneurysm was 20.2 % (95 % CI = 19.4-20.9 %). Among ruptured bAVMs with associated aneurysms, the aneurysm was the source of hemorrhage in 49.2 % (95 % CI = 43.7-54.7 %) of cases. Flow-related aneurysms were the most common source of aneurysm rupture (78.5 %, 95 % CI = 70.6-84.9 %). Infratentorial bAVM-associated aneurysms presented a higher risk of rupture (60 %, 95 % CI = 47.4-71.9 %) when compared with supratentorial lesions (29 %, 95 % CI = 21.4-38.5 %). Endovascular treatment of aneurysms associated with bAVMs had a cure rate of 80.0 % (95 % CI = 73.3-85.3 %), complication rate of 8.7 % (95 % CI = 5.5-13.1 %), and a good neurological outcome rate of 78.8 % (95 % CI = 72.5-83.9 %). CONCLUSIONS Twenty percent of bAVMs harbored arterial aneurysms. The presence of aneurysm increases the risk of bleeding of the bAVM, especially when flow-related or infratentorially located. Aneurysms associated with bAVMs should be treated promptly. Selective endovascular treatment of bAVM-associated aneurysms appears safe and effective.
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Ma L, Huang Z, Chen XL, Ma J, Liu XJ, Wang H, Ye X, Wang SL, Cao Y, Wang S, Zhao YL, Zhao JZ. Periventricular Location as a Risk Factor for Hemorrhage and Severe Clinical Presentation in Pediatric Patients with Untreated Brain Arteriovenous Malformations. AJNR Am J Neuroradiol 2015; 36:1550-7. [PMID: 26089316 DOI: 10.3174/ajnr.a4300] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/16/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The morphologic features of brain arteriovenous malformations differ between children and adults; therefore, our aim was to analyze various features of brain arteriovenous malformations to assess the risk of hemorrhage in children. MATERIALS AND METHODS We identified all consecutive children admitted to Beijing Tiantan Hospital for brain arteriovenous malformations between July 2009 and April 2014. The effects of demographic characteristics and brain arteriovenous malformation morphology on hemorrhage presentation, annual bleeding rates, postnatal hemorrhage, and immediate posthemorrhagic neurologic outcomes were studied by using univariate and multivariable regression analyses. RESULTS A total of 108 pediatric brain arteriovenous malformation cases were identified, 66 (61.1%) of which presented with hemorrhage. Of these, 69.7% of ruptured brain arteriovenous malformations were in a periventricular location. Periventricular nidus location (OR, 3.443; 95% CI, 1.328-8.926; P = .011) and nidus size (OR, 0.965; 95% CI, 0.941-0.989; P = .005) were independent predictors of hemorrhagic presentation. The annual hemorrhage rates in children with periventricular brain arteriovenous malformations were higher at 6.88% (OR, 1.965; 95% CI, 1.155-3.341; P < .05). The hemorrhage-free survival rates were also lower for children with periventricular brain arteriovenous malformations (log-rank, P = .01). Periventricular location (hazard ratio, 1.917; 95% CI, 1.131-3.250; P = .016) and nidus size (hazard ratio, 0.983; 95% CI, 0.969-0.997; P = .015) were associated with hemorrhage after birth in pediatric brain arteriovenous malformations. An ordinal analysis showed lower immediate posthemorrhage mRS in patients with periventricular brain arteriovenous malformations (OR for greater disability, 2.71; 95% CI, 1.03-7.11; P = .043). CONCLUSIONS Small periventricular brain arteriovenous malformations were associated with increased hemorrhage risk in pediatric patients. Cautious follow-up of children with untreated periventricular brain arteriovenous malformations is recommended because of a higher hemorrhage risk and potentially more severe neurologic outcomes.
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Affiliation(s)
- L Ma
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - Z Huang
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - X-L Chen
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - J Ma
- Neuroradiology (J.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - X-J Liu
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - H Wang
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.)
| | - X Ye
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.)
| | - S-L Wang
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.)
| | - Y Cao
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - S Wang
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
| | - Y-L Zhao
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China Center for Stroke (Y.-L.Z., J.-Z.Z.), Beijing Institute for Brain Disorders, Beijing, P. R. China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China.
| | - J-Z Zhao
- From the Departments of Neurosurgery (L.M., Z.H., X.-L.C., X.-J.L., H.W., X.Y., S.-L.W., Y.C., S.W., Y.-L.Z., J.-Z.Z.) China National Clinical Research Center for Neurological Diseases (L.M., Z.H., X.-L.C., X.-J.L., Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China Center for Stroke (Y.-L.Z., J.-Z.Z.), Beijing Institute for Brain Disorders, Beijing, P. R. China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease (Y.C., S.W., Y.-L.Z., J.-Z.Z.), Beijing, P. R. China
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KELLNER CHRISTOPHERP, MCDOWELL MICHAELM, PHAN MICHELLEQ, CONNOLLY ESANDER, LAVINE SEAND, MEYERS PHILIPM, SAHLEIN DANIEL, SOLOMON ROBERTA, FELDSTEIN NEILA, ANDERSON RICHARDCE. Number and location of draining veins in pediatric arteriovenous malformations: association with hemorrhage. J Neurosurg Pediatr 2014; 14:538-45. [PMID: 25238624 PMCID: PMC9879622 DOI: 10.3171/2014.7.peds13563] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECT The significance of draining vein anatomy is poorly defined in pediatric arteriovenous malformations (AVMs). In adult cohorts, the presence of fewer veins has been shown to lead to an increased rate of hemorrhage, but this phenomenon has not yet been studied in pediatric AVMs. This report analyzes the impact of draining vein anatomy on presentation and outcome in a large series of pediatric AVMs. METHODS Eighty-five pediatric patients with AVMs were treated at the Columbia University Medical Center between 1991 and 2012. Charts were retrospectively reviewed for patient characteristics, clinical course, neurological outcome, and AVM angioarchitectural features identified on the angiogram performed at presentation. Univariate analyses were performed using chi-square test and ANOVA when appropriate; multivariate analysis was performed using logistic regression. RESULTS Four patients were excluded due to incomplete records. Twenty-seven patients had 2 or 3 draining veins; 12 (44.4%) of these patients suffered from hemorrhage prior to surgery. Fifty-four patients had 1 draining vein; 39 (72.2%) of these 54 suffered from hemorrhage. Independent predictors of hemorrhage included the presence of a single draining vein (p = 0.04) and deep venous drainage (p = 0.02). Good outcome (modified Rankin Scale [mRS] score < 3) on discharge was found to be associated with higher admission Glasgow Coma Scale (GCS) scores (p = 0.0001, OR 0.638, 95% CI 0.40-0.93). Poor outcome (mRS score > 2) on discharge was found to be associated with deep venous drainage (p = 0.04, OR 4.68, 95% CI 1.1-19.98). A higher admission GCS score was associated with a lower discharge mRS score (p = 0.0003, OR 0.6, 95% CI 0.46-0.79), and the presence of a single draining vein was associated with a lower mRS score on long-term follow-up (p = 0.04, OR 0.18, 95% CI 0.032-0.99). CONCLUSIONS The authors' data suggest that the presence of a single draining vein or deep venous drainage plays a role in hemorrhage risk and ultimate outcome in pediatric AVMs. Small AVMs with a single or deep draining vein may have the highest risk of hemorrhage.
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Sheth SA, Potts MB, Sneed PK, Young WL, Cooke DL, Gupta N, Hetts SW. Angiographic features help predict outcome after stereotactic radiosurgery for the treatment of pediatric arteriovenous malformations. Childs Nerv Syst 2014; 30:241-7. [PMID: 23892391 DOI: 10.1007/s00381-013-2231-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Arteriovenous malformations (AVMs) are a frequent cause of hemorrhagic stroke in children. Stereotactic radiosurgery (SRS) is an established treatment for these lesions, particularly those that are surgically inaccessible. Because only complete AVM obliteration is believed to protect against the future risk of hemorrhage, identifying lesion characteristics that predict response to therapy is an important objective. The goal of this study is to evaluate the influence of angiographic features of AVMs on the rate of obliteration following treatment with SRS. METHODS This is a retrospective cohort study of pediatric patients (age ≤18 years) treated with Gamma Knife SRS for cerebral AVMs between 2000 and 2012. Detailed angiographic data at the time of initial angiographic evaluation were prospectively recorded by experienced neurointerventional radiologists. The primary outcome was the rate of obliteration on a 3-year follow-up angiogram. RESULTS We identified 42 pediatric patients treated with SRS for cerebral AVMs. Twenty-seven patients completed 3-year angiographic follow-ups. Complete obliteration was seen in 30%, partial response in 67%, and no response in 4%. Higher SRS dose was associated with complete obliteration. Larger AVM diameter, presence of multiple draining veins, and presence of multiple draining veins reaching a sinus were associated with partial response. In this small cohort, diffuse AVM borders, presence of aneurysm, and pre-SRS embolization were not associated with obliteration. CONCLUSIONS Our study identifies AVMs in the pediatric population with a nidus diameter of <2.5 cm and a solitary draining vein as the most likely to undergo complete obliteration after SRS treatment.
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Affiliation(s)
- Sunil A Sheth
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Toma AK, Davagnanam I, Ganesan V, Brew S. Cerebral Arteriovenous Shunts in Children. Neuroimaging Clin N Am 2013; 23:757-70. [DOI: 10.1016/j.nic.2013.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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