Clinical and morphological pattern of brain arteriovenous malformations (BAVMs) in a Tertiary Care Hospital in Bangladesh

Abstract

BackgroundWe have conducted this study to examine the clinical and morphological pattern of brain arteriovenous malformations (BAVMs) along with their treatment and short term outcome in a tertiary care hospital in Bangladesh. This retrospective chart review was carried out from the records of neuro-endovascular division at Department of Neurology, Dhaka Medical College Hospital (DMCH) from January 2010 to June 2013. A total 60 patients were evaluated. All the necessary information regarding the demographic, clinical, morphologic and treatment profile was gathered through a predesigned questionnaire. To our knowledge, we have the largest cohort of BAVM patients in Bangladesh and this is the first of this kind of study done in Bangladesh.ResultsThe mean age at diagnosis was 30.3 years with a standard deviation of ±14.3 and the majority was teenagers (30 %). Intracerebral hemorrhage was the commonest (70 %) type of presentation at diagnosis, followed by headache (50 %), altered consciousness (50 %), vomiting (40 %) and seizure (40 %). Majority of the AVMs had feeders from anterior circulation (50 %) and most of the AVMs (73.3 %) were supplied from the main feeders, whereas the rest from distal vessels. Regarding venous drainage, AVMs drained mostly either to superficial (43.3 %) or deep (40 %) venous system. AVMs frequently had larger (40 %) nidus size and a slow to medium flow (60 %), through the nidus. An eloquent AVM location was found in 50 % of the patients. Intranidal aneurysm was found in 10 % AVM and angiopathic AVM in 13.3 %. Patients were treated by endovascular embolization (31) or surgical excision (11) or conservative approach. There was one event of death, both in embolization group and surgically treated group before discharge. The patients were followed up for 1.3 ± 0.8 years. The rate of rebleed was 6.6, 30 and 60 % during follow up in endovascular, surgical and conservatively treated group. Though five patients in conservative group died during this time, no deaths reported in intervention group (endovascular or surgery).ConclusionIntracerebral hemorrhages, headache, altered consciousness and seizure are common clinical presentations of AVM at diagnosis. The remarkable morphologic features are larger AVM size at eloquent location, medium to slow flow with frequent feeders from main vessels of anterior circulation and drainage to superficial venous systems. Endovascular embolization or surgical excision of AVM are relatively safe and effective and provides better short term outcome than conservative approach.

Residual brain AVMs after surgical resection: A literature review of causes and treatment considerations

“…This is younger than the mean age of 37 years reported in a study conducted by Englot et al involving 440 patients with supratentorial AVM, and 30.3 years reported in another study conducted by Chowdhury et al involving 60 patients with brain AVMs. 21 , 22 The percentage of females (56.5%) reported to have residual AVM was almost similar to that of males (43.5%), which is consistent with data from the study conducted by Englot et al (48.6% were females and 51.4% were males). 21 …”

“…This is consistent with other data showing that AVM is slightly more frequently found on the left when compared to the right cerebrum and more likely to be located supratentorially than infratentorially. 21 , 22 Supratentorially, our study found that the frontal lobe was the most common site for residual AVM (40.9% of supratentorial sites), followed by the temporal (18.2%), parietal (18.2%) and lastly occipital (13.6%) lobe. This is consistent with data showing the rate of AVM being highest in the frontal lobe (39.3%) followed by the temporal (27.4%), parietal (20.2%) and lastly occipital (13.1%) lobe.…”

“…This was followed by vomiting (40%), seizure (40%) and visual disturbance (10%). 22 In the study by Englot et al, residual AVMs were not found to be associated with seizure recurrence. 21 However, another study did find that remnant AVMs were related to higher rates of seizure recurrence.…”

“… 25 While our data showed that most residual AVMs occurred in a non-eloquent area of the brain (57.8%), data from Englot et al found that AVMs occurred more frequently in eloquent areas of the brain (60.3%) when compared to non-eloquent areas (39.7%). 21 On the other hand, the percentage of AVMs that were positive versus negative for eloquence was found to be equal in the study by Chowdhury et al 22 One would expect that location in an eloquent area of the brain would warrant higher level of caution during resection to preserve healthy tissue, and would hence lead to a higher potential of residual AVM from occurring. Our unexpected finding might perhaps be attributed to the tendency of AVMs in eloquent areas to be referred to tertiary centers that are more well-equipped with use of extensive or advanced intraoperative monitoring (e.g., indocyanine green video angiography), resulting in lower rates of residual AVMs occurring.…”

“…We also found that more residual AVMs were associated with hemorrhage (78.6%), similar to findings from Chowdhury et al (70.0%) and Englot et al (54.8%). 21 , 22 Hemorrhage is a well-documented complication in cases of incomplete AVM obliteration. The risk is increased in patients with previous AVM hemorrhage, deep venous drainage, infratentorial or deep AVM location and presence of an aneurysm.…”