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From the Departments of Radiology (D.H.D., W.L.Y., M.C.V., J.P.-S.),
Anesthesiology (W.L.Y., S.J.), Neurological Surgery (W.L.Y., J.P.M., J.P.-S.),
Medicine (R.R.S.), and Neurology (H.M., H.C.K., A.H., J.P.M.), College of
Physicians and Surgeons, Columbia University, New York, NY; Stroke Unit,
Neurologische Klinik, Universitätsklinikum Benjamin Franklin, Freie
Universität Berlin, Germany (H.M.).
Correspondence to William L. Young, MD, P & S Box 46, Columbia University, College of Physicians & Surgeons, 630 W 168th St, New York, NY 10032. E-mail WLY1{at}columbia.edu
Purpose—The purpose of this study
was to define the influence of feeding mean arterial
pressure (FMAP) in conjunction with other morphological or clinical
risk factors in determining the probability of hemorrhagic
presentation in patients with cerebral arteriovenous
malformations (AVMs).
Methods—Clinical and angiographic data from 340 patients with
cerebral AVMs from a prospective database were reviewed. Patients were
identified in whom FMAP was measured during superselective angiography.
Additional variables analyzed included AVM size, location,
nidus border, presence of aneurysms, and arterial
supply and venous drainage patterns. The presence of
arterial aneurysms was also correlated with site of
bleeding on imaging studies.
Results—By univariate analysis, exclusively
deep venous drainage, periventricular venous drainage,
posterior fossa location, and FMAP predicted hemorrhagic
presentation. When we used stepwise multiple logistic
regression analysis in the cohort that had FMAP measurements
(n=129), only exclusively deep venous drainage (odds ratio [OR], 3.7;
95% confidence interval [CI], 1.4 to 9.8) and FMAP (OR, 1.4 per
10 mm Hg increase; 95% CI, 1.1 to 1.8) were independent
predictors (P<0.01) of hemorrhagic
presentation; size, location, and the presence of
aneurysms were not independent predictors. There was also no
association (P=0.23) between the presence of
arterial aneurysms and subarachnoid
hemorrhage.
Conclusions—High arterial input pressure (FMAP) and
venous outflow restriction (exclusively deep venous drainage) were the
most powerful risk predictors for hemorrhagic AVM
presentation. Our findings suggest that high intranidal
pressure is more important than factors such as size, location, and the
presence of arterial aneurysms in the
pathophysiology of AVM hemorrhage.
© 1998 American Heart Association, Inc.
Original Contributions
Feeding Artery Pressure and Venous Drainage Pattern Are Primary Determinants of Hemorrhage From Cerebral Arteriovenous Malformations
Key Words: cerebral arteriovenous malformations • cerebral circulation • cerebral hemorrhage • cerebrovascular disorders
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