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Long-term outcomes of pediatric arteriovenous malformations: the 30-year Pittsburgh experience
Michael M McDowell1,2, Nitin Agarwal2, Gordon Mao3
11Division of Neurological Surgery, Children's Hospital of Pittsburgh.
Insights
Multimodality treatment for pediatric arteriovenous malformations (pAVMs) achieves high functional independence. Treatment choice did not significantly impact outcomes when considering factors like Spetzler-Martin grade.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Vascular Malformations
Background:
- Pediatric arteriovenous malformations (pAVMs) are rare and challenging to treat.
- Treatment decisions for pAVMs are influenced by modality availability and provider expertise.
Purpose of the Study:
- To present the University of Pittsburgh's experience with multimodality treatment of pAVMs.
- To analyze outcomes and identify factors associated with poor outcomes in pAVM patients.
Main Methods:
- Retrospective cohort study of 212 pAVM patients (1988-2018).
- Patients had access to surgical, endovascular, and radiosurgical options.
- Univariate and multivariate analyses were used to compare outcomes, defining poor outcome as modified Rankin Scale (mRS) score ≥ 3.
Main Results:
- 31.4% of patients experienced a poor outcome.
- Factors associated with poor outcomes included no treatment, hemorrhage requiring craniotomy, preoperative mRS score, and Spetzler-Martin score.
- Radiographic obliteration rate was 79.4% with 5 recurrences noted years after treatment.
Conclusions:
- Comprehensive multimodality treatment leads to high rates of long-term functional independence in pAVM patients.
- Treatment choice did not significantly alter outcomes when accounting for Spetzler-Martin grade and presenting morbidity.
- Long-term screening is crucial due to rare but delayed recurrences.
Objective:
The study of pediatric arteriovenous malformations (pAVMs) is complicated by the rarity of the entity. Treatment choice has often been affected by the availability of different modalities and the experience of the providers present. The University of Pittsburgh experience of multimodality treatment of pAVMs is presented.
Methods:
The authors conducted a retrospective cohort study examining 212 patients with pAVM presenting to the University of Pittsburgh between 1988 and 2018, during which patients had access to surgical, endovascular, and radiosurgical options. Univariate analysis was performed comparing good and poor outcomes. A poor outcome was defined as a modified Rankin Scale (mRS) score of ≥ 3. Multivariate analysis via logistic regression was performed on appropriate variables with a p value of ≤ 0.2. Seventy-five percent of the cohort had at least 3 years of follow-up.
Results:
Five patients (2.4%) did not receive any intervention, 131 (61.8%) had GKRS alone, 14 (6.6%) had craniotomies alone, and 2 (0.9%) had embolization alone. Twenty-two (10.4%) had embolization and Gamma Knife radiosurgery (GKRS); 20 (9.4%) had craniotomies and GKRS; 8 (3.8%) had embolization and craniotomies; and 10 (4.7%) had embolization, craniotomies, and GKRS. Thirty-one patients (14.6%) were found to have poor outcome on follow-up. The multivariate analysis performed in patients with poor outcomes was notable for associations with no treatment (OR 18.9, p = 0.02), hemorrhage requiring craniotomy for decompression alone (OR 6, p = 0.03), preoperative mRS score (OR 2.1, p = 0.004), and Spetzler-Martin score (OR 1.8, p = 0.0005). The mean follow-up was 79.7 ± 62.1 months. The confirmed radiographic obliteration rate was 79.4% and there were 5 recurrences found on average 9.5 years after treatment.
Conclusions:
High rates of long-term functional independence (mRS score of ≤ 2) can be achieved with comprehensive multimodality treatment of pAVMs. At this center there was no difference in outcome based on treatment choice when accounting for factors such as Spetzler-Martin grade and presenting morbidity. Recurrences are rare but frequently occur years after treatment, emphasizing the need for long-term screening after obliteration.
