Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies

Abstract

Spontaneous (non-traumatic) intracerebral haemorrhage (ICH) has a high case-fatality and leaves many survivors disabled. Clinical characteristics and outcome seem to vary according to the cause of ICH, but population-based comparisons are scarce. We studied two prospective, population-based cohorts to determine differences in outcome [case-fatality and modified Rankin Scale (mRS)] after incident ICH due to brain arteriovenous malformations (AVM) [Scottish Intracranial Vascular Malformation Study (SIVMS), n = 90] and spontaneous ICH [Oxford Vascular Study (OXVASC), n = 60]. Patients with AVM-ICH were younger, had lower pre-stroke and admission blood pressure (BP), higher admission Glasgow Coma Scale (GCS) and were more likely to have an ICH in a lobar location than patients with spontaneous ICH (sICH). Case fatality throughout 2-year follow-up was greater following sICH than AVM-ICH [34/56 (61%) versus 11/90 (12%) at 1 year, odds ratio (OR) 11 (95% Confidence Interval (CI) 5-25)], as was death or dependence (mRS >or= 3) [40/48 (83%) versus 26/65 (40%) at 1 year, OR 8 (3-19)]. Differences in outcome persisted following stratification by age and sensitivity analyses. In multivariable analyses of 1 year outcome, independent predictors of death were sICH (OR 21, 4-104) and increasing ICH volume (OR 1.03, 1.01-1.05), and independent predictors of death or dependence were sICH (OR 11, 2-62) and GCS on admission (OR 0.79, 0.67-0.93). Outcome after AVM-ICH is better than after sICH, independent of patient age and other known predictors of ICH outcome.

The Risk of Stroke or Clinical Impairment After Stereotactic Radiosurgery for ARUBA-Eligible Patients

“…21,22 Applying a 1% annual hemorrhage rate to our hypothetical patient aged 45 years, the lifetime risk of BAVM rupture decreases to 30%. If the chance of serious morbidity or mortality after a BAVM hemorrhage is in the range of 27% to 40%, 6,7 then the lifetime risk of death or significant clinical impairment would be approximately 10%. Therefore, to provide clinical benefit for patients with unruptured BAVM, if such low long-term hemorrhage rates are correct, the risk of BAVM treatment must be less than the natural history of these lesions to justify intervention.…”

“…5 Second, the morbidity associated with arteriovenous malformations (AVM) bleeding may be less than previously thought. 6,7 Third, the risk of neurological injury after treatment of unruptured BAVM may be greater than previously described. [8][9][10] A randomized trial of unruptured brain arteriovenous malformations (ARUBA) was designed to compare the risk of observation versus prophylactic intervention for patients diagnosed with unruptured BAVM.…”

Smash-U

“…Based on previous literature, prognosis of ICH related to arteriovenous malformation was known to be better 24 and that of anticoagulationrelated ICH worse than with other ICH. 14 -16 The ICH score developed by Hemphill and coworkers has been validated and used to evaluate the outcome of patients with ICH.…”

Role of Embolization for Cerebral Arteriovenous Malformations

“…In 2009, van Beijnum et al reported a 40% rate of death or dependence in their population-based cohort 12 months after AVM-related intracerebral hemorrhage (ICH). 28 A more optimistic report from Hartmann et al found a 16% rate of at least moderately disabling deficit and no death after incident AVM hemorrhage in 115 patients. 29 From their review of the literature, Bendok et al assessed the risk of death after an AVM-associated hemorrhage to be from 10% to 15% while overall morbidity and mortality was estimated to be 15% per episode of hemorrhage.…”