Reappearance of arteriovenous malformations after complete resection of ruptured arteriovenous malformations: true recurrence or false-negative early postoperative imaging result?

Abstract

OBJECTIVE Ruptured arteriovenous malformations (AVMs) are often obliterated after emergency microsurgical treatment. However, some studies have reported AVM recurrence after the obliteration of ruptured AVMs. The authors report their experience with AVM recurrence after successful microsurgical treatment of ruptured AVMs. METHODS The authors reviewed the medical data of 139 consecutive patients who underwent microsurgery at the authors' institution for ruptured AVM between 2002 and 2012. Each patient underwent a conventional cerebral angiography examination immediately after the surgery. Subsequent follow-ups were performed with MR angiography after 6 months, and, if there was no indication of AVM recurrence, patients were followed up with conventional cerebral angiography between 1 and 2 years after the treatment; pediatric patients were followed up until age 18 years. Recurrence was defined as new radiological evidence of an AVM at the site of a ruptured AVM or a new hemorrhage in patients with angiographically documented AVM obliteration on postoperative angiograms. RESULTS The mean age of the patients at the time of ruptured AVM diagnosis was 30.8 years (SD ± 5, range 4-69 years), and 44 of the patients were younger than 18 years (the mean age at diagnosis in this pediatric subgroup was 11.4 years [range 4-17.9 years]). Complete AVM obliteration after the initial microsurgery was observed in 123 patients (89.5%). Reappearance of an AVM was noted in 7 patients between 12 and 42 months after the treatment, and all of these patients were younger than 18 years. The recurrent AVM was located in an eloquent zone in 4 patients, and deep venous drainage was noted in 3 patients. Radiosurgery was performed in 6 of these patients, and 1 patient underwent another microsurgical procedure. The authors noted only one rebleeding due to an AVM recurrence during the latency period after radiosurgery. CONCLUSIONS The recurrence of an AVM is fairly rare and affects mostly pediatric patients. Therefore, especially in children, long-term angiographic follow-up is required to detect AVM recurrence or an AVM remnant. The authors stress the need for discussion involving a multidisciplinary neurosurgical team to decide on treatment in cases of any AVM recurrence or remnant.

Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

“…446 In all cases, long-term follow-up, including posttreatment DSA, is critical because recurrence rates are as high as 11%. 447,448 Typically, a perioperative and 1-year postoperative DSA may be considered, followed by MRI/MRA annually for up to 5 years. 439,441,448 Arteriovenous Fistula Imaging.…”

Advocating Intraluminal Radiation Therapy in Cerebral Arteriovenous Malformation Treatment

“…Recently, Aboukaïs et al analyzed the subject and reported the recurrence as a fairly rare case (7/138 cases) affecting mostly pediatric patients. They recommend particularly long-term angiographic follow-up in children to detect AVM recurrence or remnants [96].…”

Predictive Value of MRI in Diagnosing Brain AVM Recurrence after Angiographically Documented Exclusion in Children

“…Complete excision of the bAVM nidus with obliteration of arteriovenous shunting is required to eliminate the risk of hemorrhage. Although there is little in the neurosurgical literature about recurrent bAVMs, with sporadic case reports and series describing bAVM recurrence after angiographic confirmation of obliteration, [27][28][29] they are likely more common than previously thought. A recent meta-analysis of this literature showed that bAVM recurrence occurred in 2.7% of reported adult series and in nearly 10%-15% of children.…”