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

Ma, Li; Huang, Zheng; Chen, X.-L.; Ma, Jun; Liu, X.-J.; Wang, H.; Ye, X.; Wang, S.-L.; Cao, Yong; Wang, S.; Zhao, Yuanli; Zhao, Jizong

doi:10.3174/ajnr.a4300

Cited by 20 publications

(30 citation statements)

References 36 publications

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“…Analyzing the natural history of AVMs, several studies did not show a relationship between location and bleeding risk . Ma et al . analyzed pediatric patients with AVMs seeking risk factors for hemorrhagic presentation and subsequent hemorrhage (follow‐up), obtaining conflicting results.…”

Section: Discussionmentioning

confidence: 99%

Grades of brain arteriovenous malformations and risk of hemorrhage and death

Stefani

Ribeiro

Mohr

2019

Ann Clin Transl Neurol

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Objective To assess the relationship of the grade of unruptured and untreated Brain Arteriovenous Malformations (AVMs), with the risk of subsequent stroke and death during follow‐up. Methods This prospective study was drawn from a cohort of adult patients with unruptured AVMs, who participated in the conservative treatment arm (medical management only for headache or seizures) of the randomized clinical trial of unruptured brain AVMs (ARUBA study). The grade of AVMs (Spetzler–Martin scale) was dichotomized into categories: AVMs of grades I and II were considered low grade; AVMs of grades III and IV were considered high grade. There were no grade V AVM patients in ARUBA. The primary outcome was symptomatic stroke (hemorrhagic or ischemic – documented by imaging) or death. Results The conservative treatment group had 123 patients (“as treated” analysis). 71 (57.7%) had lesions characterized for this analysis as low‐grade lesions and 52 (42.2%) as high grade. From the total of 10 (8.13%) primary outcomes, three occurred (4.22%) in low‐grade AVMs and seven (13.46%) in high‐grade AVMs (P = 0.0942). Interpretation Statistical analysis of the cohort of patients with unruptured and untreated AVMs from ARUBA study showed that the graduation categories (Spetzler–Martin grades) were not associated with the outcome of subsequent stroke or death.

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Section: Discussionmentioning

confidence: 99%

Grades of brain arteriovenous malformations and risk of hemorrhage and death

Stefani

Ribeiro

Mohr

2019

Ann Clin Transl Neurol

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“…The periventricular brain includes not only a vital structure in the deep brain and brain stem but also important subcortical tracts, which are not classified as either deep brain or eloquent region. Our previous data indicated that 87% of periventricular ruptured bAVMs had parenchymatous hemorrhage with or without intraventricular extension, which could lead to the disruption of important nucleus and/or tracts [8], and parenchymal hemorrhage is associated with increased morbidity in bAVM [3, 18]. These features might explain the reason for higher risk for severe hemorrhage of periventricular bAVM.…”

Section: Discussionmentioning

confidence: 99%

“…Previous reports identified posterior fossa, eloquent location, and associated aneurysm as potential predictors for severe hemorrhagic presentation in ruptured bAVM [7]. Our recent study in pediatric patients suggested a trend toward poorer neurological function at presentation and more emergency intervention in periventricular bAVM [8]. In this study with follow-up data before treatment, we aimed to (1) assess the neurological function after hemorrhagic presentation and subsequent hemorrhage and at follow-up in children with untreated bAVMs; (2) explore predictive features of severe hemorrhage in pediatric bAVM.…”

Section: Introductionmentioning

confidence: 87%

“…The AVM database at our institution is a prospectively maintained database collecting demographic, clinical, and neuroradiological data for all patients with a confirmed angiographic or histological diagnosis of intracranial AVM treated at our institute [8]. This database was reviewed to identify all consecutive children diagnosed with bAVMs between July 2009 and December 2014.…”

Section: Methodsmentioning

confidence: 99%

“…Eloquent brain was defined as previously reported in the Spetzler-Martin grading system. bAVMs were also classified as periventricular location if the nidus (with a contrast-enhancement or flow void) contacted the ependymal lining of the ventricle on contrast-enhanced T1- and T2-weighted images [8, 13]. …”

Section: Methodsmentioning

confidence: 99%

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Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation

Ma¹,

Kim²,

Chen

et al. 2017

Cerebrovasc Dis

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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.

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