scholarly journals Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study

Children ◽  
2021 ◽  
Vol 8 (3) ◽  
pp. 215
Author(s):  
Lukasz Antkowiak ◽  
Monika Putz ◽  
Marta Rogalska ◽  
Marek Mandera
Keyword(s):  
Medical Records ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Interventional Treatment ◽  
Digital Subtraction ◽  
Brain Arteriovenous Malformations ◽  
Single Center Study ◽  
Complete Obliteration ◽  
Multimodality Approach ◽  
Related Mortality

Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.

Surgery for Unruptured Spetzler-Martin Grade 3 Brain Arteriovenous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 77 (3) ◽  
pp. 362-370 ◽  
Author(s):  
Michael Kerin Morgan ◽  
Nazih Assaad ◽  
Miikka Korja
Keyword(s):  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Late Recurrence ◽  
Adverse Outcomes ◽  
Brain Arteriovenous Malformations ◽  
Complete Obliteration ◽  
Martin Grade ◽  
Grade 3 ◽  
Permanent Neurological Deficit

Abstract BACKGROUND: There is uncertainty regarding the management of unruptured Spetzler-Martin grade 3 brain arteriovenous malformations (SMG3 ubAVM). OBJECTIVE: To analyze our series of patients treated by surgery. METHODS: A single-surgeon database of consecutively enrolled bAVMs (between 1989 and 2014) was analyzed. Adverse outcomes due to surgery were assigned within the first 6 weeks following surgery and outcome was prospectively recorded and assigned at the last follow-up visit by using modified Rankin Scale (mRS) score. RESULTS: Of the 137 reviewed patients, 112 (82%) were treated by surgery, 15 (11%) were treated elsewhere or by radiosurgery, and 10 (7%) were recommended for conservative management. Surgery for SMG3 ubAVM was associated with adverse outcomes with a new permanent neurological deficit of mRS >1 in 23 of 112 (21%) patients. Permanent neurological deficit leading to a mRS >2 from surgery was 3.6% (95% confidence interval, 1.1%-9.1%). Late recurrence of a bAVM occurred in 3 of 103 (2.9%) patients who had complete obliteration of bAVM confirmed immediately after surgery and who were subsequently later followed with radiological studies during the mean follow-up period of 3.0 years (range, 6 days to 18.8 years). CONCLUSION: When discussing surgical options for SMG3 ubAVM, a thorough understanding of the significance and incidence of adverse events and outcomes is required to fully inform patients. For our series, the additional subclassification of SMG ubAVM (based on variables contributing to the SMG or age) would not have been of use.

scholarly journals International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation

2017 ◽  
Vol 19 (2) ◽  
pp. 127-135 ◽  
Author(s):  
Dale Ding ◽  
Robert M. Starke ◽  
Hideyuki Kano ◽  
David Mathieu ◽  
Paul P. Huang ◽  
...  
Keyword(s):  
Cohort Study ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Management Strategies ◽  
Multivariate Logistic Regression Analysis ◽  
Venous Drainage ◽  
Study Cohort ◽  
Multicenter Cohort Study ◽  
Brain Arteriovenous Malformations ◽  
Occipital Lobes

OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.

Embolization of brain arteriovenous malformations with intent to cure: a systematic review

2020 ◽  
Vol 132 (2) ◽  
pp. 388-399 ◽  
Author(s):  
Eva M. Wu ◽  
Tarek Y. El Ahmadieh ◽  
Cameron M. McDougall ◽  
Salah G. Aoun ◽  
Nikhil Mehta ◽  
...  
Keyword(s):  
Complication Rate ◽  
Treatment Strategy ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Definitive Treatment ◽  
Complication Rates ◽  
Brain Arteriovenous Malformations ◽  
Complete Obliteration ◽  
Complete Treatment ◽  
Entire Patient Cohort

OBJECTIVEEndovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.METHODSElectronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.RESULTSFifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.CONCLUSIONSWhile endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

scholarly journals Stereotactic radiosurgery for pediatric brain arteriovenous malformations: long-term outcomes

2020 ◽  
Vol 25 (5) ◽  
pp. 497-505
Author(s):  
Ching-Jen Chen ◽  
Cheng-Chia Lee ◽  
Hideyuki Kano ◽  
Kathryn N. Kearns ◽  
Dale Ding ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Cyst Formation ◽  
Tumor Formation ◽  
Long Term Outcomes ◽  
Risk Of Death ◽  
Brain Arteriovenous Malformations ◽  
Cumulative Probabilities

OBJECTIVEContrary to the better described obliteration- and hemorrhage-related data after stereotactic radiosurgery (SRS) of brain arteriovenous malformations (AVMs) in pediatric patients, estimates of the rarer complications, including cyst and tumor formation, are limited in the literature. The aim of the present study was to assess the long-term outcomes and risks of SRS for AVMs in pediatric patients (age < 18 years).METHODSThe authors retrospectively analyzed the International Radiosurgery Research Foundation pediatric AVM database for the years 1987 to 2018. AVM obliteration, post-SRS hemorrhage, cyst formation, and tumor formation were assessed. Cumulative probabilities, adjusted for the competing risk of death, were calculated.RESULTSThe study cohort comprised 539 pediatric AVM patients (mean follow-up 85.8 months). AVM obliteration was observed in 64.3% of patients, with cumulative probabilities of 63.6% (95% CI 58.8%–68.0%), 77.1% (95% CI 72.1%–81.3%), and 88.1% (95% CI 82.5%–92.0%) over 5, 10, and 15 years, respectively. Post-SRS hemorrhage was observed in 8.4% of patients, with cumulative probabilities of 4.9% (95% CI 3.1%–7.2%), 9.7% (95% CI 6.4%–13.7%), and 14.5% (95% CI 9.5%–20.5%) over 5, 10, and 15 years, respectively. Cyst formation was observed in 2.1% of patients, with cumulative probabilities of 5.5% (95% CI 2.3%–10.7%) and 6.9% (95% CI 3.1%–12.9%) over 10 and 15 years, respectively. Meningiomas were observed in 2 patients (0.4%) at 10 and 12 years after SRS, with a cumulative probability of 3.1% (95% CI 0.6%–9.7%) over 15 years.CONCLUSIONSAVM obliteration can be expected after SRS in the majority of the pediatric population, with a relatively low risk of hemorrhage during the latency period. Cyst and benign tumor formation after SRS can be observed in 7% and 3% of patients over 15 years, respectively. Longitudinal surveillance for delayed neoplasia is prudent despite its low incidence.

Abstract 55: Selection and Outcomes of Multimodality Interventional Treatment for Unruptured Arteriovenous Malformations in a Single Institution

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Daisuke Maruyama ◽  
Hisae Mori ◽  
Tetsu Satow ◽  
Hiroharu Kataoka ◽  
Sei Sugata ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Primary Outcome ◽  
Intervention Group ◽  
Interventional Treatment ◽  
Single Institution ◽  
Conservative Group ◽  
Brain Arteriovenous Malformations ◽  
The Mean ◽  
Grade Iii

Objective: The present study aimed to evaluate the selection and outcomes of multimodal interventional treatment for unruptured brain arteriovenous malformations (AVMs) in A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA)-eligible patients in a single institution. Methods: We retrospectively reviewed the data of 94 patients with unruptured and untreated AVMs, who had modified Rankin scale (mRS) scores of 0 or 1 at our institution between 2002 and 2014. The patients were divided into an intervention group and a conservative group, and the outcomes were compared. Similar to ARUBA, we defined the primary outcome as the composite endpoint of death or symptomatic stroke. The mRS was used to assess the functional outcome. Results: Of the 94 patients, 75 were included in the intervention group and 19 were included in the conservative group. Additionally, among the 94 patients, 58, 29, and 7 patients had Spetzler-Martin grade I/II, III, and IV/V AVMs, respectively. The number of male patients and the mean age of the patients were significantly lower in the intervention group than in the conservative group (58.6% vs. 84.2%, P=0.03 and 40.8±13.9 vs. 48.4±18.4 years, P=0.04, respectively). However, no significant difference in the proportion of patients with grade I/II AVMs was noted between the groups (65.3% vs. 47.3%). In the intervention and conservative groups, the mean follow-up periods were 59.2±41.6 and 72.8±39.2 months, respectively (P=0.20), and the primary outcome occurred in 9 (12.3%) and 3 (17.6%) patients, respectively (P=0.56). The proportion of patients with a mRS score ≥2 at last follow-up was not significantly different between the two groups (6.9% vs. 11.7%). In the intervention group, the incidence of death or stroke was lower and functional outcomes were better among patients with grade I/II AVMs than among patients with grade III AVMs (4.1% vs. 20%, P=0.003 and 2.0% vs. 15.7%, P=0.04, respectively). Conclusion: The present study found that for patients with unruptured AVMs, interventional treatment is not inferior to medical treatment alone. Multimodal interventional treatment is associated with good outcomes in patients with grade I/II AVMs. However, careful selection should be considered for patients with grade III AVMs.

scholarly journals Hypofractionated Stereotactic Radiosurgery in a Large Bilateral Thalamic and Basal Ganglia Arteriovenous Malformation

2013 ◽  
Vol 2013 ◽  
pp. 1-8
Author(s):  
Janet Lee ◽  
Tomoko Tanaka ◽  
Steven Westgate ◽  
Ashish Nanda ◽  
Marshall Cress ◽  
...  
Keyword(s):  
Basal Ganglia ◽  
Natural History ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Intensity Modulated Radiotherapy ◽  
Neurological Deficits ◽  
Digital Subtraction ◽  
Intensity Modulated ◽  
Complete Obliteration ◽  
Hypofractionated Stereotactic Radiosurgery

Purpose. Arteriovenous malformations (AVMs) in the basal ganglia and thalamus have a more aggressive natural history with a higher morbidity and mortality than AVMs in other locations. Optimal treatment—complete obliteration without new neurological deficits—is often challenging. We present a patient with a large bilateral basal ganglia and thalamic AVM successfully treated with hypofractionated stereotactic radiosurgery (HFSRS) with intensity modulated radiotherapy (IMRT).Methods. The patient was treated with hypofractionated stereotactic radiosurgery to 30 Gy at margin in 5 fractions of 9 static fields with a minimultileaf collimator and intensity modulated radiotherapy.Results. At 10 months following treatment, digital subtraction angiography showed complete obliteration of the AVM.Conclusions. Large bilateral thalamic and basal ganglia AVMs can be successfully treated with complete obliteration by HFSRS with IMRT with relatively limited toxicity. Appropriate caution is recommended.

Onyx embolization of intracranial arteriovenous malformations in pediatric patients

2013 ◽  
Vol 11 (4) ◽  
pp. 431-437 ◽  
Author(s):  
Maryam Soltanolkotabi ◽  
Samantha E. Schoeneman ◽  
Tord D. Alden ◽  
Michael C. Hurley ◽  
Sameer A. Ansari ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Venous Drainage ◽  
Neurological Complications ◽  
Clinical Effects ◽  
Complication Rates ◽  
Intracranial Arteriovenous Malformations ◽  
Significant Difference ◽  
Complete Obliteration ◽  
Study Population

Object The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients. Methods All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single children's hospital over a 5-year period were collected and evaluated. Results Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03). Conclusions Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.

Treatment Outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformation-Eligible Unruptured Brain Arteriovenous Malformation Patients

Neurosurgery ◽  
2017 ◽  
Vol 83 (3) ◽  
pp. 548-555 ◽  
Author(s):  
Min Lang ◽  
Nina Z Moore ◽  
Peter A Rasmussen ◽  
Mark D Bain
Keyword(s):  
Arteriovenous Malformation ◽  
Randomized Trial ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Interventional Treatment ◽  
Brain Arteriovenous Malformation ◽  
Brain Arteriovenous Malformations ◽  
Number Of Patients ◽  
Overall Risk

Abstract BACKGROUND The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization. OBJECTIVE To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution. METHODS Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death. RESULTS A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively. CONCLUSION We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.

Sign in / Sign up

Export Citation Format

Share Document