Postoperative imaging for detection of recurrent arteriovenous malformations in children

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The optimal method for detecting recurrent arteriovenous malformations (AVMs) in children is unknown. An inherent preference exists for MR angiography (MRA) surveillance rather than arteriography. The validity of this strategy is uncertain.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective chart review was performed on pediatric patients treated for cerebral AVMs at a single institution from 1998 to 2012. Patients with complete obliteration of the AVM nidus after treatment and more than 12 months of follow-up were included in the analysis. Data collection focused on recurrence rates, associated risk factors, and surveillance methods.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 45 patients with a mean age of 11.7 years (range 0.5–18 years) were treated for AVMs via surgical, endovascular, radiosurgical, or combined approaches. Total AVM obliteration on posttreatment digital subtraction angiography (DSA) was confirmed in 27 patients, of whom the 20 with more than 12 months of follow-up were included in subsequent analysis. The mean follow-up duration in this cohort was 5.75 years (median 5.53 years, range 1.11–10.64 years). Recurrence occurred in 3 of 20 patients (15%). Two recurrences were detected by surveillance DSA and 1 at the time of rehemorrhage. No recurrences were detected by MRA. Median time to recurrence was 33.6 months (range 19–71 months). Two patients (10%) underwent follow-up DSA, 5 (25%) had DSA and MRI/MRA, 9 (45%) had MRI/MRA only, 1 (5%) had CT angiography only, and 3 (15%) had no imaging within the first 3 years of follow-up. After 5 years posttreatment, 2 patients (10%) were followed with MRI/MRA only, 2 (10%) with DSA only, and 10 (50%) with continued DSA and MRI/MRA.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>AVM recurrence in children occurred at a median of 33.6 months, when MRA was more commonly used for surveillance, but failed to detect any recurrences. A recurrence rate of 15% may be an underestimate given the reliance on surveillance MRA over angiography. A new surveillance strategy is proposed, taking into account exposure to diagnostic radiation and the potential for catastrophic rehemorrhage.</jats:p></jats:sec>

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.…”

“…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. MRI and MRA are useful in the evaluation of AVFs but have limitations.…”

Role of follow-up imaging after resection of brain arteriovenous malformations in pediatric patients: a systematic review of the literature

“…However, Morgenstern et al showed that digital subtraction angiography (DSA) is more sensitive than MRI in detecting AVM recurrence and recommended DSA at 1, 3, and 5 years postresection and every 5 years thereafter. 25 Other groups have reported cases in which MRI may have missed subtle AVM recurrences. 5 While DSA may be more sensitive in detecting AVM recurrence, 1,5,21 MRI has successfully detected asymptomatic recurrences in several documented cases in which results suggestive of AVM recurrence were often followed up with DSA.…”

Management of intracerebral hemorrhage in pediatric neurosurgery

“…They carry an annual risk of hemorrhage of approximately 3.2%, a 5–10% mortality rate, and a 50% risk of neurological morbidity. [ 4 23 ] The large majority of AVMS are clearly evident on DSA, although several authors dating back several decades have described angiographically “occult” AVMs that were obscured following rupture. [ 24 27 ] Hypotheses for this phenomenon include possible lesional thrombosis, compressive occlusion of lesion from hematoma, transient vasospasm, or small nidus.…”

“…AVMs in children are fraught with a high recurrence rate (as high as 14%),[ 23 ] especially in lesions with a diffuse nidus[ 15 ] or deep venous drainage. There are no definitive guidelines for postoperative surveillance, however, undoubtedly, DSA has the highest resolution and sensitivity.…”