Validation of the Ruptured Arteriovenous Malformation Grading Scale in a pediatric cohort

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  • 1 Department of Neurological Surgery, University of California, San Francisco;
  • | 2 Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California, San Francisco;
  • | 3 Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco;
  • | 4 Department of Radiology and Biomedical Imaging, University of California, San Francisco;
  • | 5 Department of Pediatrics, University of California, San Francisco, California; and
  • | 6 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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OBJECTIVE

Pediatric brain arteriovenous malformations (AVMs) are the leading cause of spontaneous intracranial hemorrhage (SICH) in children. Although the incidence of SICH is low in pediatric populations, such events cause substantial morbidity. The recently created Ruptured Arteriovenous Malformation Grading Scale (RAGS) is proposed as a reliable and novel grading system to specifically serve as a predictor of clinical outcomes in patients following AVM rupture, similar to the Hunt and Hess (HH) grade for ruptured aneurysms. While these data are promising, pediatric patients were notably absent from the original study validating the RAGS. Therefore, correlation of the RAGS score with clinical outcomes following AVM rupture in individuals younger than 18 years of age using the RAGS score is needed. The objective of this study was to validate the RAGS in a cohort of pediatric patients with AVMs who presented with hemorrhage, thereby demonstrating the score’s generalizability, and expanding its external validity.

METHODS

A cohort of children with ruptured AVMs were retrospectively reviewed. Using disability, measured by the modified Rankin Scale (mRS), as the response variable, the area under the receiver operating characteristic curve (AUROC) was calculated for patients based on their RAGS scores for three time periods. The AUROC values were then compared with those generated by two commonly used clinical grading systems, the HH classification and Glasgow Coma Scale.

RESULTS

A total of 81 children who presented with ruptured AVMs were included in the study, with a mean follow-up duration of 4 years. The RAGS score outperformed other clinical grading scales in predicting mRS scores, with AUROC values of 0.81, 0.82, and 0.81 at three distinct follow-up periods.

CONCLUSIONS

The RAGS score correlated well with the clinical outcome after AVM rupture in pediatric patients. Additional validation studies across multiple treatment centers are needed to further demonstrate the generalizability of the scoring system.

ABBREVIATIONS

AUROC = area under the receiver operating characteristic curve; AVM = arteriovenous malformation; GCS = Glasgow Coma Scale; HH = Hunt and Hess; mRS = modified Rankin Scale; RAGS = Ruptured Arteriovenous Malformation Grading Scale; SICH = spontaneous intracranial hemorrhage.

Diagram from Behbahani et al. (pp 488–496).

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

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