Long-term outcome of 106 consecutive pediatric ruptured brain arteriovenous malformations after combined treatment.
OBJECTIVE
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.
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Thomas
T
Blauwblomme
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Marie
M
Bourgeois
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Philippe
P
Meyer
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Stéphanie
S
Puget
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Federico
F
Di Rocco
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Nathalie
N
Boddaert
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Michel
M
Zerah
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Francis
F
Brunelle
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.).
Christian Sainte
CS
Rose
From the Université Paris Descartes, Sorbonne Paris Cité, Paris, France (T.B., S.P., F.D.R., N.B., M.Z., F.B., C.S.R., O.N.); Departments of Pediatric Neurosurgery (T.B., M.B., S.P., F.D.R., M.Z., C.S.R.), Anesthesiology (P.M.), and Neuroradiology (N.B., F.B., O.N.), Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; and Department of Neuroradiology, INSERM UMR 894 Sainte-Anne Hospital, Paris, France (O.N.). o.naggara@ch-sainte-anne.fr.
Olivier
O
Naggara
D000293:Adolescent; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000000981:diagnostic imaging / Q000453:epidemiology; D008297:Male; D012189:Retrospective Studies; D012422:Rupture, Spontaneous / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology
arteriovenous malformations; neurosurgery; radiosurgery; therapeutic embolization; treatment outcome