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Influence of angioarchitecture on management of pediatric intracranial arteriovenous malformations
  1. Dale Ding
  1. Correspondence to Dr Dale Ding, Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22908, USA; dmd7q{at}

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I read with great interest the paper by Ellis et al.1 The authors retrospectively reviewed the angiographic features of 135 pediatric patients of mean age 10.1 years (range 0–19 years) who were referred to the 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 arteriovenous malformation (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) as independent predictors of hemorrhagic presentation.

Given the relatively little information available regarding the natural history of pediatric compared with adult AVMs, this study represents an important contribution to the pediatric AVM literature. As the authors note, there is an increased tendency to treat aggressively AVMs—especially ruptured ones—in children compared with 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 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 as 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 microsurgical resection in order to rapidly eliminate future hemorrhage risk. Additionally, the authors did not distinguish infratentorial location by brainstem versus cerebellum. Recently, the University of California San Francisco 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.

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.


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  • Competing interests None.

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

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