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Original research
Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations
  1. Michael J Ellis1,
  2. Derek Armstrong2,
  3. Shobhan Vachhrajani1,
  4. Abhaya V Kulkarni1,
  5. Peter B Dirks1,2,
  6. James M Drake1,
  7. Edward R Smith3,
  8. R Michael Scott3,
  9. Darren B Orbach4
  1. 1Department of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
  2. 2Department of Neuroradiology, Hospital for Sick Children, Toronto, Ontario, Canada
  3. 3Department of Neurosurgery, Children's Hospital Boston, Boston, Massachusetts, USA
  4. 4Department of Neurointerventional Radiology, Children's Hospital Boston, Boston, Massachusetts, USA
  1. Correspondence to Dr D B Orbach, Department of Neurointerventional Radiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA; darren.orbach{at}


Background and objective To date, there have been few published studies examining the relationship between arteriovenous malformation (AVM) angioarchitecture and hemorrhagic presentation among children with cerebral AVMs. This study examines this relationship in this unique population, in whom symptomatic presentation of cerebral AVM is the norm rather than the exception.

Methods A cohort of children with AVMs from 2000 to 2011 were included. Predictors studied included patient age, gender and angioarchitectural features, including AVM location, nidus size and morphology, venous drainage, presence of venous outflow lesions and associated aneurysms. Predictors of hemorrhagic presentation were assessed using multivariate logistic regression.

Results 135 children (70 males, mean age 10.1 years) were included. 86/135 (63.7%) children presented with hemorrhage, 18 (13.3%) with seizures, 17 (12.6%) with headaches or neurological deficits and 14 (10.4%) were asymptomatic. AVM location, morphology and the presence of associated aneurysm, venous ectasia, draining vein stenosis and single draining vein were not significantly associated factors. After multivariate analysis, AVM size (OR 0.57, 95% CI 0.43 to 0.77; p<0.01), exclusive deep venous drainage (OR 4.94, 95% CI 1.30 to 18.8; p=0.02) and infratentorial location (OR 9.94, 95% CI 1.71 to 51.76; p=0.01) were independently associated with hemorrhagic presentation.

Conclusion Smaller AVM size, exclusive deep venous drainage and infratentorial location are specific angioarchitectural factors independently associated with initial hemorrhagic presentation in children with AVMs.

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  • Funding Partial support for some of the Canadian investigators was provided by the Ontario Stroke System Research Program.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the institutional review board of the Hospital for Sick Children Toronto and the Children's Hospital Boston.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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