Faculty Bibliography

Seizures are the second most common presenting symptom of arteriovenous malformations (AVMs) in children. Although radiosurgery has been found to be a safe and effective alternative treatment, the outcome of seizure control in children after radiosurgery for AVMs is unknown. Between 1987 and 1994, 72 children under the age of 18 years were treated with gamma knife radiosurgery for AVMs at our institution. Fifteen patients (21%) had seizures as part of their clinical course. There were 11 boys and 4 girls with ages varying from 2 to 17 years (median 16 years). Seizures included: generalized tonic-clonic (n = 8); focal motor or sensory (n = 4); partial complex (n = 2), and a combination of generalized and partial complex (n = 1). Nine lesions were in cortical locations; six were subcortical. Spetzler-Martin grades included: II (n = 7); III (n = 4); IV (n = 2), and VI (n = 2). During follow-up after radiosurgical treatment, 11 of 13 patients (85%) were seizure free and off anticonvulsant therapy (mean follow-up 47 months). Two patients had a significant improvement in their seizures but continue on medication. Two of the 72 patients (3%) developed seizures after treatment and remain on medication. Seizure outcome was not associated with the location or complete obliteration of the lesion. We conclude that stereotactic radiosurgery, as a non-invasive alternative, is associated with a good outcome for the AVM as well as AVM-related seizures in children.

BACKGROUND AND PURPOSE: Arteriovenous malformations (AVMs) have an overall 2% to 4% annual risk of hemorrhage. The purpose of this study was to determine whether specific clinical and radiographic factors predispose AVMs to bleed and to predict the bleeding risk for individual AVM patients. METHODS: We reviewed the clinical histories and cerebral angiograms of 315 AVM patients who underwent stereotactic radiosurgery at our center. One half of the patient data (analysis cohort) was used to determine risk factors for bleeding and to construct AVM hemorrhage risk groups. These risk groups were then tested with the second half of the patient data (test cohort). RESULTS: The mean AVM volume was 4.0 +/- 3.4 mL (approximate maximum diameter of 2 cm). One hundred ninety-six initial hemorrhages occurred in 10,348 patient-years for an annual initial bleed rate of 1.89%; 44 of these 196 patients had a repeat bleed in 591 patient-years for an annual rebleed rate of 7.45%. The overall crude annual hemorrhage rate was 2.40%. Multivariate analysis revealed three factors associated with hemorrhage: history of a prior bleed (relative risk [RR], 9.09; 95% confidence interval [CI], 5.44 to 15.19; P < .001), a single draining vein (RR, 1.66; 95% CI, 1.13 to 2.38; P < .01), and a diffuse AVM morphology (RR, 1.64; 95% CI, 1.12 to 2.46; P < .01). Four AVM hemorrhage risk groups were constructed on the basis of the significant factors. The annual rate of bleeding was 0.99% for low-risk AVMs, 2.22% for intermediate-low-risk AVMs, 3.72% for intermediate-high-risk AVMs, and 8.94% for high-risk AVMs. CONCLUSIONS: Analysis of a large group of AVM patients who underwent stereotactic radiosurgery demonstrated that small AVMs have an annual hemorrhage risk similar to that of the general AVM population. AVM patients have a wide variability of bleeding risk that can be predicted from their clinical presentation and the angiographic characteristics of the AVM. The management of AVM patients should be based not only on the morbidity of the proposed treatment but also those factors that predispose individual patients to either a low or high hemorrhage risk.