Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations

Abstract

Background and objective To date, there have been few published studies examining the relationship between arteriovenous malformation (AVM) angioarchitecture and hemorrhagic presentation among children with cerebral AVMs. This study examines this relationship in this unique population, in whom symptomatic presentation of cerebral AVM is the norm rather than the exception. Methods A cohort of children with AVMs from 2000 to 2011 were included. Predictors studied included patient age, gender and angioarchitectural features, including AVM location, nidus size and morphology, venous drainage, presence of venous outflow lesions and associated aneurysms. Predictors of hemorrhagic presentation were assessed using multivariate logistic regression.Results 135 children (70 males, mean age 10.1 years) were included. 86/135 (63.7%) children presented with hemorrhage, 18 (13.3%) with seizures, 17 (12.6%) with headaches or neurological deficits and 14 (10.4%) were asymptomatic. AVM location, morphology and the presence of associated aneurysm, venous ectasia, draining vein stenosis and single draining vein were not significantly associated factors. After multivariate analysis, AVM size (OR 0.57, 95% CI 0.43 to 0.77; p<0.01), exclusive deep venous drainage (OR 4.94, 95% CI 1.30 to 18.8; p¼0.02) and infratentorial location (OR 9.94, 95% CI 1.71 to 51.76; p¼0.01) were independently associated with hemorrhagic presentation. Conclusion Smaller AVM size, exclusive deep venous drainage and infratentorial location are specific angioarchitectural factors independently associated with initial hemorrhagic presentation in children with AVMs.

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

“…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. 7 The presence of an associated aneurysm and deep nidus location has failed to correlate with BAVM hemorrhage in all previous pediatric studies, and our data corroborate these findings.…”

“…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. In contrast to adult patients, deep location, exclusively deep venous drainage, and associated aneurysms were not significantly correlated with the appearance of hemorrhage in these children.…”

“…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.…”

“…[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.…”

Angiographic factors associated with haemorrhagic presentation of brain arteriovenous malformation in a Chinese paediatric population

“…[9][10][11] Similar studies on AVM in children are, however, scarce and mostly based on studies from Europe and North America. 12,13 Whether those angiographic features that predict haemorrhage in Caucasian children with AVM similarly predict haemorrhage in Chinese children with AVM is unknown. The objective of this multicentre study was to determine specific angiographic factors associated with haemorrhagic presentation in brain AVM in the Hong Kong Chinese paediatric population, with a view to assisting clinical decision-making regarding the optimal timing and type of treatment.…”