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From the Stroke Unit, The Neurological Institute (A.H., H.M., J.P.M.),
the Department of Neuroanesthesia (A.O., W.L.Y.), and the Department of
Interventional Neuroradiology (J.P.-S., D.H.D.), Columbia–Presbyterian
Medical Center, New York, NY, and the Stroke Unit, Neurologische Klinik,
Universitätsklinikum Benjamin Franklin, Freie Universität Berlin
(Germany) (A.H., H.-C.K., H.M.).
Correspondence to Andreas Hartmann, MD, Stroke Unit, The Neurological Institute, 710 W 168th St, New York, NY 10032. E-mail ah267{at}columbia.edu
Background and Purpose—Decisions on
invasive arteriovenous malformation (AVM) treatment are currently based
on natural-course risk estimates of AVM bleeding and assumptions on
morbidity from cerebral hemorrhage in general. However,
morbidity of AVM hemorrhage has rarely been reported. We sought
to assess the morbidity of intracranial hemorrhage in patients
with cerebral AVMs.
Methods—From a prospective AVM database, 119 patients were
analyzed: 115 had a hemorrhage as the
diagnostic event, and 27 of them suffered a second
hemorrhage during follow-up; an additional 4 patients had other
diagnostic symptoms but bled during follow-up. The type
(parenchymal, subarachnoid,
intraventricular) and location of AVM
hemorrhage were determined by CT/MR brain imaging. Disability
and neurological impairment were assessed with the Barthel Index, the
Rankin Scale, and the National Institutes of Health Stroke Scale, with
a mean follow-up time of 16.2 months.
Results—Of the 115 incident hemorrhages, 34 (30%)
were subarachnoid, 27 (23%) parenchymal, 18 (16%)
intraventricular, and 36 (31%) in combined
locations. In 54 patients (47%; 95% confidence interval [CI], 38%
to 56%) the incident hemorrhage resulted in no neurological
deficit, and an additional 43 patients (37%; 95% CI, 28% to 46%)
were independent in their daily activities (Rankin 1). Fifteen patients
(13%; 95% CI, 7% to 19%) were moderately disabled (Rankin 2 or 3),
and 3 (3%; 95% CI, 0% to 6%) were severely disabled (Rankin
Conclusions—Hemorrhage from cerebral AVMs appears to have
a lower morbidity than currently assumed. This finding encourages a
reevaluation of the risks and benefits of invasive AVM treatment.
© 1998 American Heart Association, Inc.
Original Contributions
Morbidity of Intracranial Hemorrhage in Patients With Cerebral Arteriovenous Malformation
4).
Parenchymal hemorrhages were most likely to result in a
neurological deficit (52%). Type and morbidity of hemorrhage
during follow-up were similar to incident events. Twenty (74%) of 27
patients with both incident and follow-up hemorrhages were
normal or independent (Rankin 0 or 1). None of the patients with a
hemorrhage during follow-up died during the observation
period.
Key Words: cerebral arteriovenous malformations • hemorrhage • morbidity
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