Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients / Impacto das características angioarquiteturais das malformações arteriovenosas cerebrais na apresentaçáo clínica: análise de 183 pacientes

ABSTRACT Background: The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. Objective: The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. Methods: A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). Results: A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). Conclusions: Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

RESUMO Antecedentes: A correlação entre a angioarquitetura e a apresentação clínica da Malformação Arteriovenosa do cérebro (MAVc) permanece um assunto de debate. Objetivos: Correlacionar as características angioarquiteturais das MAVc com a apresentação clínica. Métodos: Estudou-se pacientes consecutivos atendidos no Hospital Beneficência Portuguesa-SP, entre 2006 a 2016. Após análise geral, criaram-se cinco grupos de acordo com a apresentação clínica: 1- Hemorragia; 2 - Epilepsia; 3 - Cefaléia; 4 - Déficit Neurológico Progressivo (DNP) e 5 - Incidental. Características epidemiológicas (clínica e topografia) e angioarquiteturais (Classificação de Spetzler-Martin Modificada - SMM; Fluxo intranidal; Aneurismas arteriais, intranidais e venosos; Ectasia venosa; Congestão venosa; "Roubo" arterial; Vascularização dural; Drenagem Venosa Profunda) foram analisadas. Resultados: 183 pacientes foram incluídos e analisados globalmente. Após essa etapa, foram divididos nos grupos: 1 - 56 casos (30,6%); 2 - 49 casos (26,7%); 3 - 41 casos (22,4%); 4 - 28 casos (15,3%) e 5 - 9 casos (4,9%). Principais achados foram referentes a apresentação hemorrágica, na qual observamos correlação estatística positiva com o sexo feminino (P<0,02), lesões classificadas como SMM 3B (P<0,0015) e baixo fluxo (P<0,04). Relacionado à epilepsia, encontramos significância estatística que possibilitou a correlação com pacientes com idade inferior a 36 anos (P<0,001), sexo masculino (P<0,018), lesões superficiais (P<0,002), presença de ectasia venosa (P<0,003) e "roubo" arterial (P<0,01). Pacientes com DNP se apresentam com idade superior aos demais (P<0,01). Conclusões: Após análise multivariada, foi possível separar as MAV em grupos de acordo com as características angioarquiteturais, comprovando que algumas dessas características estão fortemente relacionadas a determinada manifestação.

¿Coartación de aorta en el recién nacido? No siempre es lo que parece: a propósito de un caso / Coarctation of aorta in a neonate? It is not always what it seems: an illustrative case

La coartación de aorta en neonatos se puede manifestar como insuficiencia cardíaca según el grado de obstrucción. Hay situaciones que pueden simular una coartación de aorta en los recién nacidos. Limitarse a la imagen típica de muesca aórtica en la ecocardiografía para diagnosticar una coartación de aorta puede inducir a error y demorar el diagnóstico adecuado. Se presenta el caso de un recién nacido con insuficiencia cardíaca con diagnóstico inicial de coartación de aorta y, posteriormente, de malformación arteriovenosa cerebral. Se debe considerar la malformación arteriovenosa en el diagnóstico diferencial de un recién nacido con insuficiencia cardíaca.

Coarctation of the aorta in neonates can manifest as heart failure when there is a certain degree of obstruction. There are some situations that can simulate a coarctation of the aorta in newborns. Diagnosis of coarctation of the aorta based solely on the typical aortic arch image on echocardiography can be misleading and delay an accurate diagnosis. We describe an unusual case of a newborn with heart failure who was initially diagnosed with coarctation of the aorta and then with cerebral arteriovenous malformation. We must consider the cerebral arteriovenous malformation in the differential diagnosis of a newborn with heart failure.

Atypical Developmental Venous Anomaly Associated with Single Arteriovenous Fistula and Intracerebral Hemorrhage: a Case Demonstrated by Superselective Angiography

We present a case of developmental venous anomaly associated with arteriovenous fistula supplied by a single arterial feeder adjacent to a large acute intracerebral hemorrhage. The arteriovenous fistula was successfully obliterated by superselective embolization while completely preserving the developmental venous anomaly. Two similar cases, including superselective angiographic findings, have been reported in the literature; however, we describe herein superselective angiographic findings in more detail and demonstrate the arteriovenous shunt more clearly than the previous reports. In addition, a literature review was performed to discuss the association of a developmental venous anomaly with vascular lesions.

Anesthesia and intracranial arteriovenous malformation.

Anesthetic management of intracranial arteriovenous malformation (AVM) poses multiple challenges to the anesthesiologist in view of its complex and poorly understood pathophysiology and multiple modalities for its treatment involving different sub-specialties. The diagnosis of AVM is based on clinical presentation as well as radiological investigation. Pregnant patients with intracranial AVM and neonates with vein of Galen malformation may also pose a special challenge and require close attention. Despite technological advancement, reported morbidity or mortality after AVM treatment remains high and largely depends on age of the patient, recruitment of perforating vessels, its size, location in the brain, history of previous bleed and post-treatment hyperemic complication. Anesthetic management includes a thorough preoperative visit with meticulous planning based on different modalities of treatment including anesthesia for radiological investigation. Proper attention should be directed while transporting the patient for the procedure. Protection of the airway, adequate monitoring, and maintaining neurological and cardiovascular stability, and the patient's immobility during the radiological procedures, appreciation and management of various complications that can occur during and after the procedure and meticulous ICU management is essential.

Spontaneous Partial Regression of Cerebral Arteriovenous Malformation

Arteriovenous malformation (AVM) of the brain is one of the important pathologic conditions which cause intracerebral or subarachnoid hemorrhage, epilepsy, or chronic cerebral ischemia. The spontaneous regression of cerebral AVM is reported to be very rare and more likely to occur when the AVM is small, is accompanied by hemorrhage, and has fewer arterial feeders. We report a case of right occipital AVM which at follow-up angiography performed four years later showed near-complete spontaneous regression.

Clinical Observation and Surgical Treatment of Cerebral Arteriovenous Malformation

We have had 37 patients with cerebral arteriovenous malformation and subarachnoid hemorrhage, who were admitted to the Department of Neurosurgery, Yonsei Medical Center from 1964 to 1976. All of the cerebral arteriovenous malformations were proved by cerebral angiography. Since the site of the lesions were considered to have a close relation to the neurologic deficit and the results of surgery, various analysis of clinical manifestations and of the cerebral angiographic findings were attempted. Out of 37 patients, surgery was performed in 28 and the results were analysed according to the various type of surgical procedure.