Long-Term Outcome of 106 Consecutive Pediatric Ruptured Brain Arteriovenous Malformations After Combined Treatment

Abstract

Background and Purpose-Childhood intracerebral hemorrhage is mainly attributable to underlying brain arteriovenous malformations (bAVMs). Multimodal treatment options for bAVMs include microsurgery and embolization, allowing an immediate cure, and radiosurgery, entailing longer obliteration times. Follow-up data on pediatric ruptured bAVMs are scarce, making it difficult to assess the risk of subsequent intracerebral hemorrhage. Our aim was to assess the clinical and angiographic outcome and to analyze risk factors for rebleeding during and after combined treatment of pediatric bAVMs. Methods-A prospectively maintained database of children referred to our institution between January 1997 and October 2012 for bAVMs was retrospectively queried to identify all consecutive ruptured bAVMs treated by surgery, embolization, and radiosurgery. The impact of baseline clinical and bAVM characteristics on clinical outcome, rebleeding rate, annual bleeding rate, and bAVM obliteration was studied using univariate and multivariate Cox regression analysis. Results-One hundred six children with ruptured bAVMs were followed up for a total of 480.5 patient-years (mean, 4.5 years). Thirteen rebleeding events occurred, corresponding to an annual bleeding rate of 2.71±1.32%, significantly higher in the first year (3.88±1.39%) than thereafter (2.22±1.38%; P<0.001) and in the case of associated aneurysms (relative risk, 2.68; P=0.004) or any deep venous drainage (relative risk, 2.97; P=0.002), in univariate and multivariate analysis. Partial embolization was associated with a higher annual bleeding rate, whereas initial surgery for intracerebral hemorrhage evacuation was associated with a lower risk of rebleeding. Conclusions-Associated aneurysms and any deep venous drainage are independent risk factors for rebleeding in pediatric ruptured bAVMs. Immediate surgery or total embolization might be advantageous for children harboring such characteristics, whereas radiosurgery might be targeted at patients without such characteristics. (Stroke. 2014;45:1664-1671.)

Multimodality management and outcomes of brain arterio-venous malformations (AVMs) in children: personal experience and review of the literature, with specific emphasis on age at first AVM bleed

“…In one series, mortality reached 25% when averaged over 40 years, with an improvement from 39 to 16% over this time, coinciding with technological advances [6]. The annual bleeding risk of ruptured AVMs in children was reported as 2.71% and increased when associated with aneurysms and deep venous drainage [7]. In the Blauwblomme et al study, AVMs ruptured at a mean age of 9.7 years (range 7.0–12.7).…”

Postoperative imaging for detection of recurrent arteriovenous malformations in children

“…2,8,19 Only 18%-20% of patients with AVMs present before 15 years of age, 13,17 with hemorrhage and seizure being the most common primary events. 1,5,31,32 Treatment of AVMs includes microsurgical resection, radiosurgery, endovascular embolization, or a combination of these strategies. 3,6,24,28 Accumulating evidence has demonstrated that AVMs recur in children.…”

“…4,5 The annual risk of hemorrhage in pediatric AVM is approximately 3.2% per year, 17 with 5%-10% risk of death and up to 50% risk of neurological morbidity. 1,12,15,17 Early and complete treatment of these malformations in children is therefore important.…”

Hemorrhage Risk in Pediatric Patients with Multiple Intracranial Arteriovenous Malformations

“…Obliteration of one nidus could increase the blood flow to the remaining nidi (fragile and hemorrhage-prone points in the vasculature). A recent study also reported an increased recurrent hemorrhage risk in pediatric solitary AVM patients who were partially embolized compared to those treated with complete embolization or surgical resection [37]. This is not to suggest that embolization should not be considered among the first-line treatment modalities but rather to highlight that subtotal treatment generally appears to be associated with unfavorable sequelae in MAVM patients.…”