Published Online
on September 1, 2005

A more recent version of this article appeared on October 1, 2005

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Submitted on March 1, 2005
Revised on April 7, 2005
Accepted on April 15, 2005

Long-Term Hemorrhage Risk in Children Versus Adults With Brain Arteriovenous Malformations

Heather J. Fullerton MD, MAS^*; Achal S. Achrol BSc; S. Claiborne Johnston MD, PhD; Charles E. McCulloch PhD; Randall T. Higashida MD; Michael T. Lawton MD; Stephen Sidney MD, MPH; William L. Young MD; For the UCSF BAVM Study Project

From the Departments of Neurology (H.J.F., S.C.J., W.L.Y), Pediatrics (H.J.F.), Anesthesia and Perioperative Care (A.S.A., W.L.Y.), Epidemiology and Biostatistics (S.C.J., C.E.M), Radiology (R.T.H.), and Neurological Surgery (M.T.L., W.L.Y.), and the Center for Cerebrovascular Research (A.S.A., M.T.L., W.L.Y.), University of California, San Francisco; and the Division of Research (S.S.), Kaiser Permanente Medical Care Program, Oakland, Calif.

^* To whom correspondence should be addressed. E-mail: fullertonh{at}neuropeds.ucsf.edu.

Background and Purpose--Children with brain arteriovenous malformations (BAVMs) are said to be at higher risk for intracranial hemorrhage (ICH) than adults. Although this notion affects treatment decisions, the evidence to support this claim is limited.

Methods--To compare the risk of ICH in children versus adults with BAVM, we studied all cases of BAVM evaluated at the University of California, San Francisco (January 2000 to December 2004; n=400) and Kaiser Permanente Northern California (January 1993 to December 2004; n=819). In Kaplan-Meier survival analyses, the index date was the date of initial BAVM detection; cases were censored at time of subsequent ICH (the primary outcome, defined as ICH after initial presentation), first BAVM treatment, or loss to follow-up. Cox proportional hazards models included childhood presentation (<20 years old), hemorrhagic presentation, and other potential confounders.

Results--Our study included 996 person-years of follow-up in the childhood presentation group and 3260 in the adult presentation group. In the unadjusted survival analysis, the subsequent ICH rates were similar for the 2 age groups (average annual rate 2.0% for children; 2.2% for adults; P=0.82 by log-rank test). BAVMs in childhood were more likely to present initially with ICH (P<0.001). After adjustment for presentation in the multivariate model, subsequent ICH rates were lower in children (hazard ratio, 0.10; 95% CI, 0.01 to 0.86; P=0.036).

Conclusions--Children with BAVMs do not appear to be at increased risk for a subsequent ICH compared with adults, and may even be relatively protected. Confounding by hemorrhagic presentation should be considered in any study comparing BAVM hemorrhage rates in children versus adults.

Key words: cerebral arteriovenous malformations • cerebral hemorrhage • child

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Brain Arteriovenous Malformations: Children and Adults

J.P. Mohr
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