Brain Arteriovenous Malformation Rupture Research Articles

Challenges in the management of pediatric ruptured brain arteriovenous malformation: a case report

Brain arteriovenous malformations (bAVMs) are intracranial vascular lesions characterized by abnormal connections between the arterial and venous systems without an interposed capillary bed. Pediatric bAVMs constitute merely 12–18% of all diagnosed bAVMs, but an initial finding of bAVM rupture occurs more frequently in the pediatric population than in adults, accounting for 58–77% of all pediatric bAVM admissions.1,2 Although spontaneous pediatric intracerebral hemorrhage has an annual incidence of 1.4 per 100,000 people per year, it carries a risk of severe permanent neurological deficits, occurring in 20–40% of patients and significant mortality in up to 25% of affected individuals.3,4,5 Ruptured bAVMs are the cause of 30-50% of intracranial hemorrhages in the pediatric population and the most common cause of hemorrhagic stroke in children.1 Current therapeutic approaches for ruptured bAVMs in children include open microsurgery, endovascular embolization, as well as stereotactic radiosurgery (SRS), be it isolated or as a multimodal treatment strategy. Herein, we present the case of a 6-year-old boy with a ruptured bAVM successively managed with hemicraniectomy decompression and intracranial bleeding evacuation, followed by stereotactic radiosurgery (SRS) using gamma knife for the small AVM which was inaccessible during open surgery.

Recurrence of pediatric cerebral arteriovenous malformation after obliteration by radiosurgery: a case report

The rupture of a cerebral arteriovenous malformation is the most common cause of cerebral hemorrhage in children, with recurrence rates reported to be higher than that in adults. Herein, we present the case of a 4-year-old child who initially demonstrated obliteration of a ruptured brain arteriovenous malformation after initial Gamma Knife radiosurgery, but subsequently experienced delayed recurrence, ultimately necessitating a second Gamma Knife radiosurgery procedure. By reviewing this case, we aim to explore considerations regarding the recurrence, treatment, and follow-up strategies for pediatric arteriovenous malformations.

Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review.

Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.

Risk for Brain Arteriovenous Malformation Rupture During Pregnancy and Puerperium.

The hemorrhage risk of unruptured and untreated cerebral arteriovenous malformations (AVMs) has been shown to be higher for female patients than male patients in their child bearing ages. Although it has been neurosurgical practice to advise female patients in their childbearing ages to postpone pregnancy until proven AVM obliteration, there is no literature consensus regarding this potential hemorrhage risk increase. To accurately quantify the risk increase for AVM hemorrhage during pregnancy. This study is based on data from previous publications, consisting of known age at the first AVM hemorrhage in 3425 patients. The risk increase during pregnancy could be calculated from the difference in age distribution for the first AVM hemorrhage between male patients and female patients, taking the average pregnancy time per female into account. A comparison was also made with data for all hospital discharges (13 751) in Germany 2008 to 2018 with the diagnosis brain AVM. The average pregnancy and puerperium time was 1.54 years per female in the patient population, which was used to determine the annual AVM hemorrhage risk during pregnancy to be around 9%. The increased risk during pregnancy was further evidenced by analysis of a subgroup of 105 female patients, for which pregnancy status at the time of hemorrhage was known. The quantified annual risk for AVM hemorrhage during pregnancy is about 3 times higher than that of male patients at corresponding age. This provides an important basis for advising female patients with patent AVMs about the increased risk for hemorrhage that a pregnancy would entail.

Development and validation of a model for predicting the risk of brain arteriovenous malformation rupture based on three-dimensional morphological features.

Brain arteriovenous malformation (bAVM) is an important reason for intracranial hemorrhage. This study aimed at developing and validating a model for predicting bAVMs rupture by using three-dimensional (3D) morphological features extracted from Computed Tomography (CT) angiography. The prediction model was developed in a cohort consisting of 412 patients with bAVM between January 2010 and December 2020. All cases were partitioned into training and testing sets in the ratio of 7:3. Features were extracted from the 3D model built on CT angiography. Logistic regression was used to develop the model, with features selected using L1 Regularization, presented with a nomogram, and assessed with calibration curve, receiver operating characteristic (ROC) curve and decision curve analyze (DCA). Significant variations in associated aneurysm, deep located, number of draining veins, type of venous drainage, deep drainage, drainage vein entrance diameter (Dv), type of feeding arteries, middle cerebral artery feeding, volume, Feret diameter, surface area, roundness, elongation, mean density (HU), and median density (HU) were found by univariate analysis (p < 0.05). The prediction model consisted of associated aneurysm, deep located, number of draining veins, deep drainage, Dv, volume, Feret diameter, surface area, mean density, and median density. The model showed good discrimination, with a C-index of 0.873 (95% CI, 0.791-0.931) in the training set and 0.754 (95% CI, 0.710-0.795) in the testing set. This study presented 3D morphological features could be conveniently used to predict hemorrhage from unruptured bAVMs.

Incidence and risk factors of epilepsy following brain arteriovenous malformation rupture in adult patients.

Little is known about incidence, time of onset, clinical presentation, and risk factors of epileptic seizure following brain arteriovenous malformation (bAVM) rupture. We performed a monocentric retrospective cohort study from January 2003 to March 2021. The main objective of this study was to determine the incidence of seizures after spontaneous bAVM rupture in nonepileptic adult patients and describe the corresponding clinical features. The secondary objective was to identify clinical, radiological, or biological predictors for the occurrence of de novo seizures after bAVM rupture. Of the 296 cases of bAVM rupture registered during the study period, 247 nonepileptic patients (male 53%, median age 40) were included in the study. Fifty-nine patients (23.9%) had at least one seizure after bAVM rupture. The use of preventive antiepileptic drugs (10.3 [1.5-74.1]; P = 0.02) and decompressive craniectomy (15.4 [2.0-125]; P < 0.009) were independently associated with the occurrence of epilepsy after the bAVM rupture. The factors independently associated with the absence of any seizure after the rupture were isolated intraventricular hemorrhage (0.3 [0.1-0.99]; P = 0.04) and infratentorial location of the bAVM (0.2 [0.1-0.5]; P = 0.09). The first seizure occurred within the first year or within 5years in, respectively, 83.1% and 98.3% of the patients. Epilepsy affects nearly a quarter of patients after bAVM rupture. Decompressive craniectomy represents an independent risk factor significantly associated with the occurrence of epilepsy after bAVM rupture. The introduction of preventive AEDs after rupture could be considered in these most severe patients who have a decompressive craniectomy.

Strategic neuronavigation-guided emergent endoscopic evacuation of the hematoma caused by ruptured brain arteriovenous malformation: Technical note and retrospective case series

The treatment strategy for ruptured brain arteriovenous malformations (bAVMs) in the acute phase is still controversial. We describe five consecutive cases of successful emergent endoscopic evacuation (EEE) of intracerebral hematoma (ICH) caused by ruptured bAVMs with the electromagnetic (EM)-neuronavigation system to avoid damage to the bAVMs intended to save valuable time in the emergent phase. A single-institution retrospective analysis was performed in patients with ruptured bAVMs treated by the EM-navigated EEE as part of the strategic multimodality therapy. EM-navigated EEE was performed as follows: 1) obtaining three-dimensional computed tomography to identify the location of the nidus, large draining vein, feeding artery, and hematoma; 2) using a supine position without rigid head fixation for both supra- and infratentorial hematoma; 3) planning the entry point and trajectory of the endoscope as far as possible from the location of the nidus using the EM-navigation system; 4) designing a linear skin incision line suitable for the endoscopic surgery as well as possible decompressive craniectomy; and 5) performing EM-navigated endoscopic partial evacuation of ICH. EM-navigated EEE of ICH was successfully performed for all 5 patients, resulting in partial removal of the ICH without rebleeding from bAVMs. The mean surgical time was 37 min. Subsequent strategic endovascular embolization and curative resection of bAVMs could be performed for all patients, achieving Glasgow Coma Scale score of 15. EM-navigated EEE of partial ICH may be valuable in the emergent phase of ruptured bAVMs with massive life-threatening ICH to reduce the intracranial pressure and to obtain better prognosis.

Image Characteristicộng sự of Ruptured Arteriovenous Malformations of the Brain on the Multislice Computed Tomography

This study describes the features of the image of the Ruptures Brain Arteriovenous Malformation (AVM) based on films of Multislide Computed Tomography (MSCT) at Bach Mai Hospital. The study used descriptive cross-sectional, prospective and retrospective method to analyze the MSCTs of 40 patients at the Center of Radiology, Bach Mai Hospital, from March 2019 to March 2020. The results show that the common age of the patients was &lt;40 years old and the average age was 33.88 ± 16.27; the ratio of female/male was ≈ 1.11/1; 70% of the patients suffered from headache. On admission, 52.5% of the patients were conscious (glassgow 15 points), 30% of them lost consciousness (glassgow &lt;13 points) and 17.5% were comatose; 47.5% had a syndrome of increased intracranial pressure; 22.5% with detected cerebral AVM but never treated; 77.5% with ruptured cerebral AVM in the upper floor of the cerebellum and 57.5% had it in the highly functional area; 67.5% with cerebral AVM ≤ 3cm in size. Feeding artery ≤ 3 stalks accounted for 85%, of which 1 stem accounted for the majority. Attached aneurysm accounted for 42.5%, mainly in AVM drive aneurysm (32.5%). Pure shallow drainage veins accounted for 50%. Brain parenchymal hemorrhage alone accounted for 60%. Brain parenchymal with ventricular and subarachnoid hemorrhage accounted for 37.5%. The small size hemorrhage volume ratio (&lt;30 mm) and the average size (30-60 mm) accounted for the same percentage of 45%. According to the Spetzler - Martin classification, the cerebral ruptured venous malformation drive with low resolution (I-III) accounted for 85%. Overall, MSCT provides information to help guide the treatment of cerebral hemorrhage caused by cerebral AVM.&#x0D; Keywords:&#x0D; Arteriovenous malformation of the brain, ruptured cerebral arteriovenous malformations, Multislide Computed Tomography (MSCT).&#x0D; References&#x0D; [1] R. M. Friedlander, Clinical Practice, Arteriovenous Malformations of the Brain, N Engl J Med, Vol. 356, No. 26, 2007, pp. 2704-2712, https://doi.org/10.1056/nejmcp067192.[2] J. F. Yu, A. D. Nicholson, J. Nelson et al., Predictors of Intracranial Hemorrhage Volume and Distribution in Brain Arteriovenous Malformation, Vol. 24, No. 2, 2018, pp. 183-188, https://doi.org/10.1177/1591019917749819.[3] E. Shotar, M. Debarre, N. A. Sourour et al., Retrospective Study of Long-term Outcome after Brain Arteriovenous Malformation Rupture: the RAP Score, J Neurosurg, Vol. 128, No. 1, 2018, pp. 78-85, https://doi.org/10.3171/2016.9.jns161431.[4] P. M. Thong, N. H. An, The Initial Results of Treatment Mass the Brain Arteriovenous Malformation Rupture with Surgery in Combination with Embolization in Bach Mai Hospital; Vietnam Journal of Medicine, October, No. 1, 2017, pp. 51-56 (in Vietnames). [5] R. F. Speizler, N. A. Martin, A Proposed Grading System for Arteriovenous Malformations, J Neurosurg, Vol. 108, No. 1, 2008, pp. 186-193, https://doi.org/10.3171/jns/2008/108/01/0186[6] M. Majumdar, L. A. Tan, M. Chen, Critical Assessment of the Morbidity Associated with Ruptured Cerebral Arteriovenous Malformations, J Neurointerv Surg, Vol. 8, No. 2, 2016, pp. 163-167, https://doi.org/10.1136/neurintsurg-2014-011517. [7] R. F. Spetzler, D. S. Kondziolka, R. T. Higashida et al., Comprehensive Management of Arteriovenous Malformation of the Brain and Spine, Cambridge University Press, 2015, pp. 78-85, https://doi.org/10.1080/01616412.1998.11740583[8] R. Torné, R. A. Hernández, F. Arikan et al., Posterior Fossa Arteriovenous Malformations: Significance of Higher incidence of Bleeding and Hydrocephalus, Clin Neurol Neurosurg, Vol. 134, 2015, pp. 37-43, https://doi.org/10.1016/j.clineuro.2015.04.003.

Transpacific Aeromedical Evacuation for a Ruptured Brain Arteriovenous Malformation During the COVID-19 Pandemic.

ABSTRACTThe COVID-19 pandemic has altered preexisting patient treatment algorithms and referral patterns, which has affected neurosurgical care worldwide. Brain arteriovenous malformations are complex vascular lesions that frequently present with intracerebral hemorrhage. Care for these patients is best performed at large medical centers by specialists with high volumes. The authors describe the care of a patient who presented in extremis to a resource-limited, community-sized military treatment facility (MTF) in Southeast Asia. In the MTF, the patient underwent emergent neurosurgical therapy. However, given newly implemented restrictions enacted to mitigate COVID-19 spread, local transfer for definitive care to a tertiary care facility was not possible. In order to attain definitive care for the patient, a transpacific aeromedical evacuation augmented with a critical care air transport team was utilized for transfer to a tertiary care, teaching hospital. This case demonstrates the safe treatment of a patient with hemorrhagic arteriovenous malformations and postoperative management under limited conditions in an MTF outside the CONUS. Given the unique circumstances and challenges the pandemic presented, the authors feel that this patient’s outcome was only possible by leveraging all the capability military medicine has to offer.

Factors affecting the performance of brain arteriovenous malformation rupture prediction models

BackgroundIn many cases, both the rupture rate of cerebral arteriovenous malformation (bAVM) in patients and the risk of endovascular or surgical treatment (when radiosurgery is not appropriate) are not low, it is important to assess the risk of rupture more cautiously before treatment. Based on the current high-risk predictors and clinical data, different sample sizes, sampling times and algorithms were used to build prediction models for the risk of hemorrhage in bAVM, and the accuracy and stability of the models were investigated. Our purpose was to remind researchers that there may be some pitfalls in developing similar prediction models.MethodsThe clinical data of 353 patients with bAVMs were collected. During the creation of prediction models for bAVM rupture, we changed the ratio of the training dataset to the test dataset, increased the number of sampling times, and built models for predicting bAVM rupture by the logistic regression (LR) algorithm and random forest (RF) algorithm. The area under the curve (AUC) was used to evaluate the predictive performances of those models.ResultsThe performances of the prediction models built by both algorithms were not ideal (AUCs: 0.7 or less). The AUCs from the models built by the LR algorithm with different sample sizes were better than those built by the RF algorithm (0.70 vs 0.68, p < 0.001). The standard deviations (SDs) of the AUCs from both prediction models with different sample sizes displayed wide ranges (max range > 0.1).ConclusionsBased on the current risk predictors, it may be difficult to build a stable and accurate prediction model for the hemorrhagic risk of bAVMs. Compared with sample size and algorithms, meaningful predictors are more important in establishing an accurate and stable prediction model.

Acute surgical management of children with ruptured brain arteriovenous malformation.

Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM. This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury. A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently. HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.

Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy

Background: Sporadic brain arteriovenous malformations (BAVM) are a major cause of hemorrhagic stroke in younger persons. Prior studies have reported contradictory results regarding the risk of hemorrhage during pregnancy, and there are no standard guidelines for the management of pregnant women who present with BAVM rupture. The purpose of this study is to describe maternal and fetal outcomes and treatment strategies in patients with BAVM hemorrhage during pregnancy. Methods: We performed a retrospective review of the University of California, San Francisco Brain AVM Project database for female patients who were pregnant at the time of BAVM hemorrhage between 2000 and 2017. Clinical and angiographic characteristics at presentation, BAVM treatment, and maternal outcomes using modified Rankin scale (mRS) score at presentation and 2-year follow-up were recorded. Fetal outcomes were abstracted from medical records and maternal reports. Results: Sixteen patients presented with BAVM hemorrhage during pregnancy, 81% (n = 13) of whom were in their second or third trimester. Three patients (19%) who were in their first trimester terminated or miscarried pregnancy prior to BAVM intervention. Of the remaining 13 patients, 77% (n = 10) received emergent BAVM treatment at time of hemorrhage prior to delivery, and 85% of patients achieved BAVM obliteration and good maternal outcomes (mRS 0–2) at 2-year follow-up. All patients had uncomplicated deliveries (69% cesarean and 23% vaginal) with no reports of postnatal cognitive or developmental delays in infants at 2-year follow-up. Conclusions: Our study shows good long-term maternal and fetal outcomes in ruptured BAVM patients presenting during pregnancy, the majority who received BAVM interventional treatment prior to delivery.

Secondary S100B Protein Increase Following Brain Arteriovenous Malformation Rupture is Associated with Cerebral Infarction.

Early S100B protein serum elevation is associated with poor prognosis in patients with ruptured brain arteriovenous malformations (BAVM). The purpose of this study is to determine whether a secondary elevation of S100B is associated with early complications or poor outcome in this population. This is a retrospective study of patients admitted for BAVM rupture. A secondary increase of S100B was defined as an absolute increase by 0.1 μg/L within 30 days of admission. Fisher’s and unpaired t tests followed by multivariate analysis were performed to identify markers associated with this increase. Two hundred and twenty-one ruptures met inclusion criteria. Secondary S100B protein serum elevation was found in 17.1% of ruptures and was associated with secondary infarction (p < 0.001), vasospasm-related infarction (p < 0.001), intensive care (p = 0.009), and hospital length of stay (p = 0.005), but not with early rebleeding (p = 0.07) or in-hospital mortality (p = 0.99). Secondary infarction was the only independent predictor of secondary increase of S100B (OR 9.9; 95% CI (3–35); p < 0.001). Secondary elevation of S100B protein serum levels is associated with secondary infarction in ruptured brain arteriovenous malformations.

Targeted endovascular treatment for ruptured brain arteriovenous malformations

Currently, endovascular treatment (EVT) is recommended for ruptured brain arteriovenous malformation (BAVM). When performing EVT for ruptured BAVM, curative complete embolization without complications is the ideal goal, but, more often than not, it is difficult, impossible, and dangerous. Therefore, EVT targeted toward ruptured focal weak structures plays a very important role. No previous study has comprehensively reviewed the use of targeted EVT for ruptured BAVMs. Therefore, the current paper reviews the available literature on this subject. In BAVM, the ruptured focal weak structures may include flow-related aneurysms, intranidal venous dilated structures, intranidal fistula, and venous varices or ectasia. These ruptured focal weak structures have direct and indirect imaging presentations. The indirect imaging presentations indicate various intracranial hemorrhages. In direct imaging presentations, digital subtraction angiography (DSA) has the highest degree resolution for showing ruptured focal weak structures. In addition, some magnetic resonance (MR) sequences can be useful to identify ruptured focal weak structures. Of all ruptured focal weak structures, flow-related aneurysms are considered the highest risk and require urgent occlusion. Other ruptured weak structures also need to undergo targeted EVT. After targeted EVT, a good prognosis can be obtained. Therefore, the use of targeted EVT for ruptured BAVM is promising.

Risk of Rebleeding in Patients Suffering From Ruptured Brain Arteriovenous Malformations Undergoing Subacute Treatment: A Single-Center Series and Systematic Review of the Literature

The optimal timing for treatment of ruptured brain arteriovenous malformation (BAVM) is still controversial. The present study aims to determine safety of subacute BAVM management in clinically stable patients by identifying the rate of rebleeding. Patients presenting from 2000 to 2018 with ruptured BAVM who were scheduled for BAVM treatment at least 4 weeks after initial hemorrhage were included in the present study. After neurological rehabilitation of the patient and decreased hemorrhage-induced brain swelling, subacute treatment for the ruptured BAVM was carried out. Primary outcome of the present series was defined as treatment failure resulting from rehemorrhage caused by the ruptured BAVM in patients previously labeled eligible for subacute BAVM treatment. Additionally, we performed a systematic review of the contemporary peer-reviewed literature concerning treatment strategy in patients with ruptured BAVM. Fifty-five patients suffering from ruptured BAVM were considered eligible for subacute BAVM treatment at our institution. No patient suffered from early rebleeding before definitive BAVM treatment in our institutional group. Our own patient data were then pooled with data from the literature, resulting in 166 patients suffering from ruptured BAVM who underwent subacute BAVM treatment. Of these, 1 patient (0.6%) suffered from rehemorrhage during the recovery period 130 days after initial BAVM rupture. The present series and systematic review revealed a rehemorrhage rate of 0.6% in patients suffering from ruptured BAVM who underwent subacute treatment. Therefore, subacute treatment of patients with ruptured BAVM seems safe after application of rigorous treatment algorithms to sort out patients with higher risk for rehemorrhage.

S100B Serum Elevation Predicts In-Hospital Mortality After Brain Arteriovenous Malformation Rupture.

Background and Purpose- S100B protein serum elevation has been associated with poor prognosis in neurologically ill patients. The purpose of this study is to determine whether elevation of S100B is associated with increased in-hospital mortality after brain arteriovenous malformation rupture. Methods- This is a retrospective study of patients admitted for brain arteriovenous malformation rupture. The study population was divided into derivation and validation cohorts. Univariate followed by multivariate logistic regression was used to determine whether elevation of S100B serum levels above 0.5 µg/L during the first 48 hours after admission (S100Bmax48) was associated with in-hospital mortality. Results- Two hundred and three ruptures met inclusion criteria. Twenty-three led to in-hospital mortality (11%). Mean S100Bmax48 was 0.49±0.62 µg/L. In the derivation cohort (n=101 ruptures), multivariate analysis found Glasgow coma scale score ≤8 (odds ratio, 21; 95% CI, 2-216; 0.001) and an S100Bmax48>0.5 µg/L (odds ratio, 19; 95% CI, 2-188; P=0.001) to be associated with in-hospital mortality. When applied to the validation cohort (n=102 ruptures), the same model found only S100Bmax48>0.5 µg/L (odds ratio, 8; 95% CI, 1.5-44; P=0.01) to be associated with in-hospital mortality. Conclusions- Elevated S100B protein serum level is strongly associated with in-hospital mortality after brain arteriovenous malformation rupture.

Abstract TP581: Maternal and Fetal Outcomes in Women With Brain Arteriovenous Malformation Rupture During Pregnancy

Background: Intracranial hemorrhage (ICH) is often the initial presenting symptom for patients with brain arteriovenous malformations (bAVM), which is further complicated in the setting of pregnancy. There are no standard guidelines for management of pregnant women with bAVM, and few studies have reported on maternal and fetal outcomes in those with bAVM ICH. The purpose of this descriptive study was to review our case series for maternal and fetal outcomes in women with bAVM ICH during pregnancy. Methods: We conducted a retrospective review of our database for women between the ages of 15-50 years who presented with a bAVM ICH during pregnancy between 2000-2017. Demographics, angiographic characteristics, gestational age/trimester at ICH, mode and timing of AVM treatment, and maternal (e.g. modified Rankin Scale, mRS) and fetal outcomes (e.g. healthy or intrauterine fetal death) were recorded from the medical records. Results: We identified 16 bAVM cases who were pregnant at the time of ICH. Mean age of cases was 27±6.7 years, 56% were non-Caucasian, and 81% presented with an ICH during the second or third trimester. Of 16 patients, 2 terminated pregnancies in the 1 st trimester, 1 miscarried immediately after ICH, and 13 patients carried to term (69% delivered cesarean and 23% vaginal). Of 13 patients with live births, 77% received emergent AVM treatment (embolization+resection or resection only) at time of ICH, while 3 deferred treatment until after birth. The majority of bAVMs were Spetzler-Martin grade 2 or 3 (87%), 56% had deep venous drainage, and mean AVM size was 2.5±1.2cm. At 2-year follow-up, 85% of women had good outcomes (mRS 0-2). Only one patient did worse after AVM treatment due to a permanent neurological deficit. All cases had healthy fetal outcomes at time of delivery and at 2-yr follow-up. Conclusion: Our case series suggest good fetal and maternal outcomes in ruptured bAVM patients presenting during pregnancy, the majority of which were treated before delivery. Treatment of ruptured AVMs during pregnancy should be tailored to the needs of each specific patient in close consultation with the obstetrics and neurosurgery teams.

Prognosis of Ruptured Cerebral Arteriovenous Malformations: Is It Better Than Other Causes of ICH?

Although the conventional wisdom is that intracerebral hemorrhages (ICHs) that are caused by a ruptured brain arteriovenous malformation (AVM) have a

Monitoring of central venous pressure and stroke volume variation in a case with a ruptured brain arteriovenous malformation and Fontan circulation

BackgroundPatients with complex congenital heart disease increasingly undergo noncardiac surgeries because of advancements in surgical techniques and medical management. In Fontan circulation, maintaining an adequate transpulmonary gradient is essential for preserving both pulmonary blood flow and cardiac output. However, intraoperative circulatory monitoring of Fontan patients has not been established.Case presentationA 17-year-old girl required an emergency craniotomy for ruptured arteriovenous malformation. She had a surgical history of bidirectional Glenn operation and Fontan palliation for her congenital hypoplastic left heart syndrome and double outlet right ventricle. We performed general anesthesia with continuous monitoring of central venous pressure (CVP) and stroke volume variation (SVV). Transesophageal echocardiography was not conducted because of difficulty in manipulating the probe due to the patient’s position and surgical setting. After incision of the dura, approximately 1700 ml of rapid blood loss from the arteriovenous malformation was observed in 30 min. In this period, CVP decreased from 15 to 5 mmHg or less. In contrast, there was only a slight rise in SVV from 5 to 8%. We rapidly administered fluid and then transfused blood, and CVP gradually recovered to 10–15 mmHg. During the surgery, circulatory collapse was not observed. The patient was transferred to the intensive care unit under sedation and controlled ventilation.ConclusionsCVP decreased sharply, whereas SVV rose only slightly during acute bleeding in the present case. CVP monitoring may have been useful for the management of an acute bleeding case with a Fontan circulation but SVV may not have been reliable. As more patients with a Fontan circulation undergo noncardiac surgeries, appropriate circulatory monitoring in these patients should be further investigated.

Abstract TP446: Predictors of Hemorrhagic Severity in Arteriovenous Malformation Patients

Introduction: One of the most frequent causes of non-traumatic intracerebral hemorrhage (ICH) in young adults is from a brain arteriovenous malformation (AVM) rupture. Understanding the potential spectrum of AVM outcomes is crucial in assessing treatment options. Although ICH mortality from ruptured brain AVMs is less frequent than for primary ICH, the severity of brain AVM hemorrhage is not well documented. We aimed to identify the clinical and anatomical variables associated with: (1) ICH volume and (2) intraventricular hemorrhage (IVH) presence to better prognosticate eventual clinical hemorrhage severity in brain AVM patients. Methods: ICH volume and presence of IVH (outcomes) were retrospectively assessed based on CT images for 150 patients admitted with ruptured AVMs and prospectively enrolled in our AVM database between 2000-2015. Parenchymal hemorrhage volumes were calculated using the ABC/2 method. Regression analysis was performed to assess the relationship between clinical and anatomical factors and ICH volume (proportional increase, PI) and presence of IVH (odds ratio, OR). Results: Older patients were less likely to have IVH (p=0.036). Exclusively deep venous drainage was associated with both smaller hemorrhage volumes (p&lt;0.001) and an increased likelihood of IVH (p&lt;0.001). Lobar AVM locations were associated with larger hemorrhage volumes (p&lt;0.001). Venous stenosis, based on a 5-point grading scale (5 = complete occlusion), was associated with larger hemorrhage volumes (p=0.006) and a decreased likelihood of IVH (p=0.014). Exclusively deep venous drainage (PI=0.29, 95% CI: 0.19 - 0.44), lobar location (PI=2.18, 95% CI: 1.47 - 3.24), and venous stenosis (PI=1.34, 95% CI: 1.09 - 1.64) remained significant independent predictors of hemorrhage volume in a multi-predictor model (P&lt;0.05). Similarly, exclusively deep venous drainage (OR=7.51, 95% CI: 2.69 – 21.00) and venous stenosis (OR=0.61, 95% CI: 0.41 – 0.90) remained significantly associated with IVH (P&lt;0.05). Conclusions: With the lack of a widely adopted AVM natural history score, our study provides further information regarding potential hemorrhage severity in addition to the current knowledge of hemorrhagic risk to better scrutinize patients with unruptured AVMs.