Peer-Review ReportAngioarchitectural Characteristics of Brain Arteriovenous Malformations with and without Hemorrhage
Introduction
Data from multiple diagnostic techniques for brain arteriovenous malformation (AVM) suggest an overall brain AVM detection rate of 1.3 (95% confidence interval [CI] 1.29–1.57) per 100,000 person-years (4). AVMs are congenital lesions that occur most frequently in the supratentorial region (18). Diagnosis of AVM increases with patient age, but an AVM is often detected in patients younger than 50 years old. About half of patients with AVMs present with hemorrhage followed by focal or generalized seizures (25%), headache (15%), and focal neurologic deficits and other symptoms (3). The variable angioarchitectural characteristics of AVMs may be associated with occurrence of hemorrhage (5, 10, 12, 20). Detailed understanding of AVM angioarchitecture would help us identify characteristics that correlate with hemorrhage. Knowledge of these specific factors may also help provide a morphologic basis for AVM treatment (20). We performed this study to obtain a better understanding of the factors associated with hemorrhage in AVM patients.
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Methods
During the period 1999–2008, 302 consecutive patients with cerebral AVMs were referred to our institution for endovascular embolization. Demographic, clinical, morphologic, and treatment data related to these patients were retrospectively reviewed (Table 1). Patients ranged in age from 5–65 years (mean ± SD, 28.3 ± 12.8). There were 188 male patients and 113 female patients.
Results
Of the 302 patients, 159 (52.6%) were diagnosed because of intracranial hemorrhage. The remaining 143 patients (47.4%) had a nonhemorrhagic diagnostic event, such as seizure (n = 74 [24.5%]), headache (n = 38 [12.6%]), focal neurologic deficit (n = 19 [6.3%]), or other clinical events including incidental AVM diagnoses (n = 12 [4.0%]). The annual rupture rate of AVMs in this study is 1.9% by using the period between the date of the birth of the patient and the date of the diagnosis (Figure 1).
Discussion
As a congenital lesion, cerebral AVMs came to clinical attention more than a century ago. Despite the advent of contemporary brain imaging techniques, the detection rate of AVMs over the last decade was 1.3 per 100,000 person-years, which was not increased (4). Recent data from international databases (9) and prospective population-based studies (1, 8, 19) suggest that more than half of all patients with AVM may experience intracranial hemorrhage. Other important presenting symptoms include
Conclusions
Our findings show that deep and infratentorial AVM location, AVM size <3 cm, single arterial feeder, single draining vein, combined deep and superficial drainage, presence of varices in the venous drainage, and coexisting aneurysms are independent risk factors associated with AVMs with hemorrhage. Knowledge of these risk factors is helpful in the decision-making process when treating patients with cerebral AVM.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.