Number and location of draining veins in pediatric arteriovenous malformations: association with hemorrhage

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>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 &lt; 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 &gt; 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).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>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.</jats:p></jats:sec>

Periventricular Location as a Risk Factor for Hemorrhage and Severe Clinical Presentation in Pediatric Patients with Untreated Brain Arteriovenous Malformations

“…[24][25][26][27][28] Most of these factors and results were obtained from a retrospective cohort (younger than 22 years of age) at Columbia University Medical Center. 24,26,28 Two larger studies reported results with a relatively distinct bias (a wide range of odds ratio or only radiosurgery patients), suggesting that these studies might have been underpowered to assess the impact of certain features on BAVM hemorrhage.…”

“…[24][25][26][27][28] Most of these factors and results were obtained from a retrospective cohort (younger than 22 years of age) at Columbia University Medical Center. 24,26,28 Two larger studies reported results with a relatively distinct bias (a wide range of odds ratio or only radiosurgery patients), suggesting that these studies might have been underpowered to assess the impact of certain features on BAVM hemorrhage. 25,27 In this exclusively pediatric cohort (18 years old or younger) of patients with BAVMs referred to a high-volume Chinese neurosurgery center during the past 5 years, we identified periventricular nidus location and smaller nidus size as independent predictors of hemorrhagic presentation.…”

“…A recent study of the Columbia pediatric BAVM cohort (of 81 children) identified deep venous drainage, rather than exclusively deep venous drainage, as a predictor for hemorrhage presentation. 28 Another report on 135 children with BAVMs indicated the presence of an association of exclusively deep venous drainage with hemorrhage. 25 The role of exclusively deep venous drainage should be analyzed in further studies with larger sample sizes by using standard angiographic methods, because only 9.3% of children with BAVMs had exclusively deep venous drainage in our study, which is much less than the 17%-28% rate reported in other studies.…”

“…Previous studies have identified some morphologic factors that are significant at presentation but do not necessarily predict future hemorrhages in pediatric patients with BAVMs. [24][25][26][27][28] While the long-term follow-up of prospective studies such as A Randomized Trial of Unruptured Brain Arteriovenous Malformations will clarify features that predict future hemorrhage in adults with BAVMs, these studies are less likely to be performed in pediatric patients, a group in which most patients present with hemorrhage; ethical dilemmas could arise during conservative treatment with observation of known BAVMs. 30 Assuming that the BAVM had been present since birth, thereby accumulating a large number of patient-years of follow-up, we found an overall annual hemorrhage rate of 5.47% in children with BAVMs, which is much higher than the 2.0% reported in a previous study.…”

Medical image of the week: moyamoya disease

“…Neuroimaging is the preferred method of diagnosis after high clinical suspicion of MMD or MMS. Intracranial hemorrhage and cerebral infarction can be diagnosed with computed tomography and magnetic resonance imaging/ cerebral angiogram, respectively (8,9). Recent use of magnetic resonance perfusion imaging has been shown to be crucial in diagnostics and medicalsurgical decision making.…”