Published Online
on April 13, 2006

A more recent version of this article appeared on May 1, 2006

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Submitted on October 27, 2005
Revised on December 30, 2005
Accepted on February 9, 2006

Clinical Outcome After First and Recurrent Hemorrhage in Patients With Untreated Brain Arteriovenous Malformation

Jae H. Choi MD^*; Henning Mast MD; Robert R. Sciacca EngScD; Andreas Hartmann MD; Alexander V. Khaw MD; Jay P. Mohr MD; Ralph L. Sacco MD; and Christian Stapf MD

From the Stroke Center, The Neurological Institute (J.H.C., H.M., R.R.S, A.H., A.V.K., J.P.M., R.L.S., C.S.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY; the Department of Neurology, Ernst Moritz Arndt University, Greifswald (A.V.K.), and Bergmannstrost, Halle, Germany (J.H.C., H.M.); the Department of Neurology, Hôpital Lariboisière, AP-HP, Paris, France (C.S.); and the Division of Stroke Medicine (H.M.), Nottingham, UK.

^* To whom correspondence should be addressed. E-mail: jchoi{at}neuro.columbia.edu.

Background and Purpose--The morbidity from spontaneous hemorrhage of untreated brain arteriovenous malformations (AVM) is not well described.

Methods--The 241 consecutive AVM patients (mean age 37±16 years, 52% women) from the prospective Columbia AVM Databank initially presenting with hemorrhage were evaluated using the Rankin Scale (RS) and the National Institute of Health Stroke Scale (NIHSS). From the 241 AVM patients, 29 (12%) had subsequent intracranial hemorrhage during follow-up. For further comparisons, 84 non-AVM patients with intracerebral hemorrhage from the Northern Manhattan Study (NOMAS) served as a control group.

Results--In 241 AVM patients presenting with hemorrhage the median RS was 2 and the median NIHSS was 1 (49% RS 0 to 1, 61% NIHSS <2). The median time between hemorrhage and clinical evaluation was 11 days (mean 219 days). Recurrent AVM hemorrhage during follow-up resulted in no significant increase in morbidity (median RS 2, P=0.004; median NIHSS 3, P=0.322; time between hemorrhage and study evaluation: median 55 days, mean 657 days). Among AVM-hemorrhage subtypes, parenchymatous AVM hemorrhage was associated with higher stroke morbidity (odds ratio, 2.9; 95% CI, 1.5 to 5.8 for NIHSS 2) than nonparenchymatous hemorrhages. Parenchymatous AVM hemorrhage had a significantly better outcome (median NIHSS 1) than non-AVM related hemorrhage (median NIHSS 12; P<0.0001).

Conclusions--Hemorrhage, either at initial presentation or during follow-up of untreated AVM patients appears to carry a lower morbidity than intracranial hemorrhage from other causes. These findings support a careful weighing of risks from interventional treatment and natural history.

Key words: cerebral arteriovenous malformations • intracerebral hemorrhage • intracranial hemorrhage • outcome • subarachnoid hemorrhage

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Unruptured Cerebral Arteriovenous Malformations: To Treat or Not to Treat

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