title: Multicenter assessment of morbidity associated with cerebral arteriovenous malformation hemorrhages.
abstract: BACKGROUND
  The optimal management strategy for unruptured cerebral arteriovenous malformations (AVMs) is controversial since the ARUBA trial (A Randomized trial of Unruptured Brain AVMs). An accurate understanding of the morbidity associated with AVM hemorrhages may help clinicians to formulate the best treatment strategy for unruptured AVMs.
  
  
  OBJECTIVE
  To determine the morbidity associated with initial cerebral AVM rupture in patients presenting to tertiary medical centers.
  
  
  METHODS
  Retrospective chart reviews from three tertiary academic medical centers were performed for the period between 2008 and 2014. All patients admitted with intracranial hemorrhage due to untreated AVMs were included in this study. Patient-specific variables, including demographics, imaging characteristics, neurologic examination results, and clinical outcome, were analyzed and recorded.
  
  
  RESULTS
  101 Patients met the inclusion criteria. Admission National Institutes of Health Stroke Scale (NIHSS) scores were 0, 1-9, and ≥10 in 26%, 29%, and 45% of patients, respectively. Hematoma locations were subarachnoid, intraventricular, intraparenchymal, and combined in 5%, 11%, 32%, and 52% of patients, respectively. Deep venous drainage was present in 43% of AVMs; AVM-associated aneurysms were present in 44% of patients. Emergent hematoma evacuations were performed in 37% of patients and 8% of patients died while in hospital. At discharge, of those who survived, NIHSS scores of ≥1 and ≥10 were found in 69% and 23%, respectively. At the 90-day follow-up, 34% had a modified Rankin Scale (mRS) score >2. Patients with admission NIHSS score ≥10 had significantly higher rates of midline shift, surgical hematoma evacuation, and follow-up mRS ≥3 (p<0.05).
  
  
  CONCLUSIONS
  The morbidity associated with cerebral AVM rupture appeared to be higher in our study than previously reported. Morbidity from AVM rupture should be considered as an important factor, together with variables such as risk of AVM rupture and procedural risk, in determining the optimal treatment strategy for unruptured cerebral AVMs.
authors.affiliation: Rush Medical College, Chicago, Illinois, USA.
authors.forename: Keiko
authors.initials: K
authors.lastname: Fukuda
authors.affiliation: Rush Medical College, Chicago, Illinois, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Majumdar
authors.affiliation: Department of Neurology, SUNY Upstate Medical University, Syracuse, New York, USA.
authors.forename: Hesham
authors.initials: H
authors.lastname: Masoud
authors.affiliation: Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA.
authors.forename: Thanh
authors.initials: T
authors.lastname: Nguyen
authors.affiliation: Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois, USA.
authors.forename: Amir
authors.identifier: http://orcid.org/0000-0002-7491-381X
authors.initials: A
authors.lastname: Honarmand
authors.affiliation: Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Shaibani
authors.affiliation: Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois, USA.
authors.forename: Sameer
authors.initials: S
authors.lastname: Ansari
authors.affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Lee A
authors.initials: LA
authors.lastname: Tan
authors.affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D001164:Arteriovenous Fistula / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D020300:Intracranial Hemorrhages / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009460:Neurologic Examination; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D012189:Retrospective Studies
keywords: Arteriovenous Malformation; Hemorrhage; Stroke; Vascular Malformation