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

Dale Ding University of Virginia, Department of Neurosurgery, Charlottesville, Virginia;

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Robert M. Starke University of Miami, Department of Neurological Surgery, Miami, Florida;

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Hideyuki Kano University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania;

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David Mathieu University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and

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Paul P. Huang New York University Langone Medical Center, Department of Neurosurgery, New York, New York;

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Caleb Feliciano University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico

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Rafael Rodriguez-Mercado University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico

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Luis Almodovar University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico

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Inga S. Grills Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan;

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Danilo Silva Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio;

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Mahmoud Abbassy Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio;

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Symeon Missios Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio;

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Douglas Kondziolka New York University Langone Medical Center, Department of Neurosurgery, New York, New York;

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Gene H. Barnett Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio;

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L. Dade Lunsford University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania;

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Jason P. Sheehan University of Virginia, Department of Neurosurgery, Charlottesville, Virginia;

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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.

ABBREVIATIONS

AVM = arteriovenous malformation; ICH = intracranial hemorrhage; IGKRF = International Gamma Knife Research Foundation; RBAS = radiosurgery-based AVM score; VRAS = Virginia Radiosurgery AVM Scale.
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