Clusters of Pediatric Brain Arteriovenous Malformations Link Spatial Distribution, Clinical Presentation, and...

Pediatric brain arteriovenous malformation (PbAVM) is a potentially life-threatening condition accounting for intracerebral hemorrhage and other neurological complications. Our study aimed to elucidate the relationships between PbAVM angioarchitecture, spatial distribution, and clinical presentation. This retrospective study included all consecutive PbAVMs managed in a tertiary pediatric center (2007-2023). We performed a hierarchical clustering based on quantitative imaging data and constructed a 3D MRI-based atlas. We derived and analyzed clusters for initial presentation, clinical parameters (cure, recurrent bleeding, proliferation/recurrence, seizures) and location. We included 245 pediatric brain arteriovenous malformations in 234 patients (74.8% ruptured, mean age 9.9±4 years). Hierarchical clustering delineated three clusters of PbAVMs. Cluster 1 included ruptured small slow flow PbAVMs (n = 162, 82% ruptured). Cluster 2 included ruptured and epileptic fast flow PbAVMs (n = 69, 53% ruptured, 23% epileptic), more frequently located within the right thalamus. Cluster 3 included giant PbAVMs (n = 14, 21.5% ruptured, 57% epileptic), more frequently located within the left posterior insula and right premotor area. Cluster 2 PbAVMs achieved lower rate of exclusion than Cluster 1 (HR_cure=0.34±0.23, p = 3.7.10^- 6). Cluster 3 exhibited null complete exclusion, more frequent recurrent bleeding (HR_rupture=6.83±0.61, p = 0.001) and proliferation over time (HR_{proliferation}=11.1±0.49, p = 1.10^- 6). The probabilistic analyses showed association between PbAVMs within primary motor cortex and epileptic presentation, PbAVMs within right thalamus and neurological deficit at presentation, and PbAVMs within left parietal lobe and headaches. We identified three clusters (small slow flow, fast flow, giant) of PbAVMs that demonstrated unique initial presentation, clinical course, outcomes and spatial distribution.