Risk Of First Hemorrhage Research Articles

In Reply: Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature.

Background Recommendations on the management of brain arteriovenous malformations (bAVM) with respect to pregnancy are based upon conflicting literature. Objective To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium. Methods MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible. Results From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research. Conclusion There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required.

Letter: Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature.

Letter: Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature.

Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature.

Recommendations on the management of brain arteriovenous malformations (bAVM) with respect to pregnancy are based upon conflicting literature. To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium. MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible. From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research. There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required.

RADIOSURGERY OF INTRACEREBRAL CAVERNOMAS--CURRENT HUNGARIAN PRACTICE

Radiosurgery is an increasingly popular treatment option especially for deep eloquent intracerebral cavernomas that are often too risky for surgical removal, but their re-bleed carries significant risk for persisting neurological deficit. Gamma-radiation based radiosurgery has been being available since 2007 in Hungary in Debrecen. Our aim is to summarize our experience accumulated during the first five years of treatment and to compare it to the international experience. PATIENT SELECTION AND METHODS: We retrospectively analyzed 51 cavernomas in 45 patients treated between 2008 and 2012 in terms of localization, natural history, and the effect of radiosurgery on re-bleed risk and epilepsy, and its side effects. We treated 26.5% deep eloquent (brainstem, thalamic/basal ganglia) and 72.5% superficial hemispheric cavernomas. The median presentation age was 25 years (13-60) for deep, and 45 years (6-67) for superficial cavernomas. They were treated median of 1 year after presentation. 64.5% of deep cavernomas bled before treatment, the annual risk of first hemorrhage was 2%/lesion, re-bleed risk 21.7%, with 44% persisting morbidity. 13.5% of superficial cavernomas bled prior to treatment, the risk of first bleed was 0.3%, there was no re-bleed, and 35% caused epilepsy. We used GammaART-6000TM rotating gamma system for treatment, marginal dose was 14 Gy (10-16), and treatment volume 1.38-1.53 cm3. Re-bleed risk of deep eloquent lesions fell to 4% during the first two years after treatment and to 0% thereafter, and no hemorrhage occurred from superficial lesions after treatment. Persisting morbidity in deep lesions came from adverse radiation effect in 7% and from re-bleed in 7%, and there was no persisting side effect in superficial cavernomas. 87.5% of cases of epilepsy resistant to medical therapy improved. Radiological regression was found in 37.5% and progression in 2% after treatment. Radiosurgery of cavernomas is safe and effective. Early preventive treatment for deep cavernomas carrying high surgical risk is justified. Moreover, for superficial lesions that are surgically easily accessible radiosurgery also appears to be an attractive alternative.

Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: A prospective cohort study

Introduction The aim of this study was to identify patients who are likely to benefit from surgery for unruptured brain arteriovenous malformations (ubAVMs). Materials and methods The authors’ database was interrogated for the risk and outcome of hemorrhage after referral and the outcome from surgery. Furthermore, the outcome from surgery incorporated those cases excluded from surgery because of perceived greater risk (sensitivity analysis). Finally, a comparison was made for the authors’ patients between the natural history and surgery. Data were collected for 427 consecutively enrolled patients with ubAVMs in a database that included patients who were conservatively managed. Kaplan–Meier analysis was performed on patients observed for more than 1 day to determine the risk of hemorrhage. Variables that may influence the risk of first hemorrhage were assessed using Cox proportional hazard regression models and Kaplan–Meier life table analyses from referral until the first occurrence of the following: hemorrhage, treatment, or last review. The outcome from surgery (leading to a new permanent neurological deficit with last review modified Rankin Scale [mRS] score > 1) was determined. Further sensitivity analysis was made to predict risk from surgery for the total ubAVM cohort by incorporating outcomes of surgical cases as well as cases excluded from surgery because of perceived risk, and assuming an adverse outcome for these excluded cases. Results A total of 377 patients with an ubAVM were included in the analysis of the risk of hemorrhage. The 5-year risk of hemorrhage for ubAVM was 11.5%. Hemorrhage resulted in a mRS score > 1 in 14 cases (88% [95% CI: 63%–98%]). Patients with Spetzler–Ponce Class A ubAVMs treated by surgery ( n = 190) had a risk from surgery of 1.6% (95% CI: 0.3%–4.8%) for a permanent neurological deficit leading to a mRS score > 1 and 0.5% (95% CI 2. Patients with Spetzler–Ponce Class B ubAVMs treated by surgery ( n = 107) had a risk from surgery of 14.0% (95% CI: 8.6%–22.0%) for a permanent neurological deficit leading to a mRS score > 1. Sensitivity analysis of Spetzler–Ponce Class B ubAVMs, including those in patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 15.6% (95% CI: 9.9%–23.7%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Patients with Spetzler–Ponce Class C ubAVMs treated by surgery ( n = 44) had a risk from surgery of 38.6% (95% CI: 25.7%–53.4%) for a permanent neurological deficit leading to a mRS score > 1. Sensitivity analysis of Class C ubAVMs, including those harbored by patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 60.9% (95% CI: 49.2%–71.5%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Conclusion Surgical outcomes for Spetzler–Ponce Class A ubAVMs are better than those for conservative management.

Results of ARUBA Are Applicable to Most Patients With Nonruptured Arteriovenous Malformations

2006 (Kissimmee, FL) was the last such controversy session on brain arteriovenous malformations (AVMs) at an International Stroke Conference. The patient then was somewhat older but raised similar management issues. Intervention had produced a major stroke. A dissatisfied interventionalist in the audience was overheard to murmur, “I want some answers.” A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial had just been funded by National Institutes of Neurological Diseases and Stroke (NINDS) but had not begun. Some additional information would help hemorrhage risk assessment for the current case. Evidence of previous hemorrhage, symptomatic or not, raises the risk of further hemorrhage; based on current practice, it would argue for intervention with a goal of lesion eradication. Recent onset headaches could mean she is developing venous stenosis or dilatation, thought by some a risk factor for hemorrhage, albeit not easily treated. If the AVM site straddles the arterial borderzones, risk of first hemorrhage would be lower than for sites elsewhere. To be …

RADIOSURGERY TO REDUCE THE RISK OF FIRST HEMORRHAGE FROM BRAIN ARTERIOVENOUS MALFORMATIONS

It remains unclear whether or not and to what extent stereotactic radiosurgery can reduce the risk of first intracranial hemorrhage from brain arteriovenous malformations. We performed a retrospective observational investigation of 500 patients with arteriovenous malformations who were treated with gamma knife radiosurgery. The risk of first hemorrhage was analyzed using the Cox proportional-hazards model with age at radiosurgery and angiographic obliteration included as time-dependent covariates. Three periods were defined: from birth to radiosurgery (before radiosurgery); from radiosurgery to angiographic obliteration (latency period); and from angiographic obliteration to end of the follow-up period (after obliteration). Hemorrhage was documented before radiosurgery in 318 patients (median observation period, 30.0 yr), during the latency period in 11 patients (median observation period, 2.2 yr), and after obliteration in two patients (median observation period, 5.5 yr). Compared with the period before radiosurgery, the risk of hemorrhage decreased by 86% after obliteration (hazard ratio, 0.14; 95% confidence interval, 0.03-0.55; P = 0.005), whereas the reduction observed during the latency period was not statistically significant (hazard ratio, 0.56; 95% confidence interval, 0.31-1.04; P = 0.07). Irrespective of obliteration, the risk of hemorrhage decreased by 62% after radiosurgery (hazard ratio, 0.38; 95% confidence interval, 0.22-0.67; P = 0.001). Similar results were observed when the 33 patients who had undergone previous therapy were excluded from the analysis. Stereotactic radiosurgery significantly reduces the risk of first hemorrhage from brain arteriovenous malformations. The extent of the decrease might be greater if angiography indicates the evidence of obliteration.

Radiosurgery to Reduce the Risk of First Hemorrhage from Brain Arterio-venous Malformations

Radiosurgery to Reduce the Risk of First Hemorrhage from Brain Arterio-venous Malformations

A population-based study of brain arteriovenous malformation: long-term treatment outcomes.

By undertaking long-term follow-up of a functionally isolated population study group, we sought to achieve a true picture of intrinsic brain arteriovenous malformation (BAVM). We sought to assess the validity of earlier population-based series and to determine the effects of newer treatment methods on the overall morbidity and mortality of BAVM. We excluded other intracranial vascular pathologies by defining criteria. By retrospective and prospective study, 240 patients with BAVM were followed for a mean of 10.11 years from first diagnosis. Death rates were as follows: all causes, 12.9%; all BAVM related, 8.75%; BAVM related during conservative management, 24.6%; and BAVM related during active management, 3.9% (P=0.031). Mean diagnosis-to-death interval was 10.6 years. Oxford neurological disability scale grades of 209 survivors (July 2001) were as follows: grades 0 to 2, 74.1%; grade 3, 17.2%; and grades 4 to 5, 9.5%. Death rates were higher for patients who had bled or suffered nonhemorrhagic neurological deficit at original presentation. Incidence of first-ever hemorrhage in untreated patients was as follows: 0 to 9 years, 4.6% (P=0.0035); 30 to 39 years, 21% (P=0.02); and 60 to 69 years, 40.0% (P=0.045). The first bleed was fatal in 4.6%. We find no evidence of a substantial undiagnosed reservoir of nonsymptomatic BAVM. All BAVM are potentially hazardous. The great majority of BAVM patients become symptomatic during the patient's lifetime, and the majority will bleed. The risk of first hemorrhage is lifelong and rises with age. Compared with earlier population-based series, our low overall patient mortality is predominantly due to higher proportions of active treatment in the 1980s and 1990s.

Bleeding from cerebral arteriovenous malformations as part of their natural history.

The case records of 191 patients with a cerebral arteriovenous malformation (AVM) were reviewed to determine bleeding characteristics of these lesions. Possible influences of age, sex, the location and size of the AVM, type of initial hemorrhage, and condition of the patients were analyzed. Of these 191 patients, 102 had a single hemorrhage, 32 had a recurrent hemorrhage, and 57 never bled. The follow-up period for patients with an unruptured AVM was a mean of 4.8 years and a maximum of 31 years; for those with a ruptured AVM, the mean was 2 years, and the maximum 37 years. Size of the AVM was significantly related to the risk of first hemorrhage. The average yearly risk for first hemorrhage was between 2% and 3%. Bleeding occurred most frequently in the 11- to 35-year-old age group. The risk of rebleeding increased with advancing age. Among 93 patients followed after their AVM had ruptured, the risk of rebleeding was 6% in 1 year. After the first year, the average rebleeding rate was about 2% per year up to 20 years.