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• Re:The Influence of Angioarchitecture on Management of Pediatric Intracranial Arteriovenous Malformations
  Darren B. Orbach
  Published on: 13 April 2016
• The Influence of Angioarchitecture on Management of Pediatric Intracranial Arteriovenous Malformations
  Dale Ding
  Published on: 13 April 2016

• Published on: 13 April 2016

  Re:The Influence of Angioarchitecture on Management of Pediatric Intracranial Arteriovenous Malformations

  • Darren B. Orbach
  • Other Contributors:
    • Edward R. Smith, Department of Neurosurgery, Boston Children's Hospital

  We read with interest Dr. Ding's response to our manuscript, "Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations," and we thank him for his gracious comments. In response to his question regarding whether brain AVM angioarchitecture influences our particular treatment strategy, we would point out that the overwhelming majority of our pediatric patients wi...

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  We read with interest Dr. Ding's response to our manuscript, "Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations," and we thank him for his gracious comments. In response to his question regarding whether brain AVM angioarchitecture influences our particular treatment strategy, we would point out that the overwhelming majority of our pediatric patients with brain AVM present with hemorrhage or with an AVM-related neurological symptom. Thus, we are rarely in the position of evaluating an entirely asymptomatic AVM, in which case particular features of the angioarchitecture might weigh heavily in assessing whether to proceed. Our treatment strategy, once the decision has been made to proceed, is designed to as definitively as possible ensure complete removal of the AVM, wherever feasible. We thus favor surgical resection, with preoperative embolization used where this would lower morbidity and improve surgical outcome. Given the age of our patients, we tend to favor radiotherapy less than would typically be the case in an adult cohort. We hope to describe the details of our multidisciplinary approach to treatment in a future publication.

  Darren B. Orbach & Edward R. Smith

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  The Influence of Angioarchitecture on Management of Pediatric Intracranial Arteriovenous Malformations

  • Dale Ding

  I have read, with great interest, the paper by Ellis et al. titled 'Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations [1]. The authors retrospectively reviewed the angiographic features of 135 pediatric patients, mean age 10.1 years (range 0-19 years), who were referred to Hospital for Sick Children in Toronto, Canada and Boston Children's Hospital ove...

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  I have read, with great interest, the paper by Ellis et al. titled 'Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations [1]. The authors retrospectively reviewed the angiographic features of 135 pediatric patients, mean age 10.1 years (range 0-19 years), who were referred to Hospital for Sick Children in Toronto, Canada and Boston Children's Hospital over a period of 11 years from 2000 to 2011. The most common presenting symptoms were hemorrhage (64%), seizure (13%), and focal neurological deficits or headache (13%). The authors sought to identify angiographic features associated with AVM rupture at presentation. Multivariate logistic regression analysis identified smaller size (P<0.01), exclusive deep venous drainage (P=0.02), and infratentorial location (P=0.01) to be independent predictors of hemorrhagic presentation.

  Given the relatively little information available regarding the natural history of pediatric compared to adult AVMs, this study represents an important contribution to the pediatric AVM literature. As the authors note, there is an increased tendency to aggressively treat AVMs, especially ruptured ones, presenting in children compared to those in adults due to the higher exposure to hemorrhage risk and hemorrhage- related morbidity and mortality by children. Given what is currently known regarding the natural history of AVMs, which is largely derived from adult patients, this rationale is seems valid [2]. A Randomized Trial of Unruptured Brain AVMs (ARUBA) is a study of adult patients only [3]. It is unknown whether the results of ARUBA, which are pending imminent publication, will alter the management of unruptured pediatric AVMs.

  It would be very interesting to know how the patients described in this study were treated and whether hemorrhagic presentation and AVM angioarchitectural features influenced the treatment strategies. Although the method by which AVM obliteration is achieved is biased, at times significantly, by the treating physician and institution, no single modality, including endovascular embolization, microsurgical resection, and radiosurgery, has emerged superior to its counterparts. For example, AVMs with smaller size and exclusive deep venous drainage, which typically implies deep location, are ideal radiosurgery targets [4-5]. However, in the setting of AVM rupture, some may advocate for microsurgical resection in order to rapidly eliminate future hemorrhage risk. Additionally, the authors did not distinguish infratentorial location by brainstem versus cerebellum. Recently, the UCSF cerebrovascular group described cerebellar AVMs as anatomically distinct lesions from cerebral AVMs with a higher propensity for hemorrhagic presentation [6]. Not surprisingly, cerebellar AVMs are significantly more conducive than brainstem AVMs to surgical resection therefore underscoring the importance of distinguishing the two locations.

  In summary, the authors should be congratulated for identifying independent predictors of hemorrhagic presentation in a relatively large cohort of pediatric AVMs combined from two tertiary pediatric referral centers of international repute. Given the difficulty of obtaining prospective data regarding the natural history of pediatric AVMs, the cerebrovascular community will continue to rely on this study and others like it to guide decision-making for the management of these rare and complex vascular lesions.

  References

  1. Ellis, M.J., D. Armstrong, S. Vachhrajani, A.V. Kulkarni, P.B. Dirks, J.M. Drake, E.R. Smith, R.M. Scott, and D.B. Orbach, Angioarchitectural features associated with hemorrhagic presentation in pediatric cerebral arteriovenous malformations. J Neurointerv Surg, 2013. 5(3): p. 191-5. 2. Gross, B.A. and R. Du, Natural history of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg, 2013. 118(2): p. 437-43. 3. Mohr, J.P., A.J. Moskowitz, C. Stapf, A. Hartmann, K. Lord, S.M. Marshall, H. Mast, E. Moquete, C.S. Moy, M. Parides, J. Pile-Spellman, R. Al-Shahi Salman, A. Weinberg, W.L. Young, A. Estevez, I. Kureshi, and J.L. Brisman, The ARUBA trial: current status, future hopes. Stroke, 2010. 41(8): p. e537-40. 4. Kano, H., D. Kondziolka, J.C. Flickinger, H.C. Yang, T.J. Flannery, N.R. Awan, A. Niranjan, J. Novotny, and L.D. Lunsford, Stereotactic radiosurgery for arteriovenous malformations, part 2: management of pediatric patients. J Neurosurg Pediatr, 2012. 9(1): p. 1-10. 5. Yen, C.P., S.J. Monteith, J.H. Nguyen, J. Rainey, D.J. Schlesinger, and J.P. Sheehan, Gamma Knife surgery for arteriovenous malformations in children. J Neurosurg Pediatr, 2010. 6(5): p. 426-34. 6. Rodriguez-Hernandez, A., H. Kim, T. Pourmohamad, W.L. Young, and M.T. Lawton, Cerebellar arteriovenous malformations: anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery, 2012. 71(6): p. 1111-24.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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