doi: 10.1161/01.STR.0000181775.06537.d9
(Stroke. 2005;36:2060.)
© 2005 American Heart Association, Inc.
Editorials |
Brain Arteriovenous Malformations
Children and Adults
From the Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, New York, NY
Correspondence to J.P. Mohr, MS, MD, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032. E-mail jpm10{at}columbia.edu
Key Words: cerebral arteriovenous malformations • child • cerebral hemorrhage
Although intracranial hemorrhages,1 interest in brain arteriovenous malformations (BAVMs) is expanding from its origins as a neuropathologic curiosity to the treatment-oriented specialties of neurological surgery, interventional neuroradiology, radiosurgery/therapy, and clinical neurology, and is even emerging as a subject in neuroepidemiology.
Recent insights from uncontrolled series: argue for some genetic derangements in the origin of some of the lesions2,3; have revised some issues of pathophysiology4–7; track the risk of hemorrhage over time8; suggest the risk for hemorrhage can be predicted by vascular factors discoverable by noninvasive or minimally invasive imaging9,10; indicate many initial hemorrhage syndromes are mild,11 more so than that caused by non-BAVM parenchymal or aneurysmal subarachnoid hemorrhages12; have reassessed the outcomes from intervention in a variety of forms after initial hemorrhage13–15; raise questions concerning the safety and value of intervention before hemorrhage16,17; and support a proposal for randomized trials for BAVMs discovered before rupture,18,19 to name but a few of the directions in which work is proceeding in this field.
The prevalence of BAVMs is difficult to estimate, given the lack of a population subject to uniform brain imaging.20 Some insights are provided from rare studies from the likes of uniform magnetic resonance screening of clinically normal recruitees for the German Air Force,21 showing a relative frequency of <0.7% of asymptomatic brain lesions, including among them BAVMs. However, most information comes from nonuniform imaging done in recently reported large prospective population settings, in which 0.5 of 100 000 cases of BAVM discovered after hemorrhage compare with up to 0.9 of 100 000 discovered before hemorrhage.22,23
But what of children? In most studies, the focus is on adults,19 with some more recent studies also including children, most of them either small cohorts of children24,25 or containing reference to them as part of a larger survey. Among the latter, population-based data from the ongoing New York Islands AVM study26 suggest 20% of all AVMs are detected in patients <21 years of age, including 8% in children 
10 years of age. Among the latter, the relative proportion of incident hemorrhage appears to be significantly higher (65%) when compared with the entire cohort (38%; P<0.01).
In this issue of Stroke, the world-renowned authors have made recourse to the large clinical databases from the University of California San Francisco and Kaiser-Permanente. In size, this cohort eclipses previous efforts and seems likely to set the new reference point. Some statisticians may be uncomfortable with the lack of precise population-based data represented here, but this is a small field, with limited data from other sources. Until even better data sources are created, findings from this study will surely attract interest. Leading the list is the observation that "... children do not appear to be at increased risk for a subsequent ICH (intracerebral hemorrhage) compared with adults and may even be relatively protected." Differing as it does from previous reports focusing mainly on adults27,28 and from other sources claiming high risks of hemorrhage recurrence in children,29,30 this inference is sure to have an impact on current views of pathophysiology and is bound to prompt controversy.
Hopefully, this publication will spur a larger effort. Among the many things lacking in the field is insight into whether and to what extent BAVM in children is a different disease than that in adults. The current publication suggests they compare favorably with adults for the first hemorrhage and follow a different course for recurrence. Given the middle-aged emergence of clinical syndromes in some patients and the stable course followed by some whose lesions are deemed too daunting for therapy at any age, those interested in treatment need better insight into whose BAVM is a static anomaly versus one best dealt with before it becomes a threat to life.
Closer study of children might help change or expand the simile for BAVMs. Although some may be time bombs, others seem like meningiomas, and some even like arachnoid cysts, more dangerous when misdiagnosed as needing treatment than they are when left undiscovered.
Footnotes
The opinions in this editorial are not necessarily those of the editors or the American Heart Association.
See related article, pages 2099–2104
References
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Related Article:
Stroke 2005 36: 2099-2104.
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