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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1590-1592

Is there an Influence of Match and Mismatch of Venous Drainage Pattern on AVM Hemorrhagic Presentation?


1 Department of Neurosurgical, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
2 Department of Neurosurgery, Linyi People Hospital, Weifang Medical University, Linyi, Shandong, China

Date of Submission18-Nov-2017
Date of Decision14-Mar-2018
Date of Acceptance22-Mar-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Xianli Lv
Litang Road 168, Changping, Beijing, 102218
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355081

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 » Abstract 


Objective: To analyze whether there is an influence of match and mismatch of venous drainage patterns on arteriovenous malformation (AVM) hemorrhagic presentation.
Methods: Consecutive 161 patients of AVM between 2014 and 2017 were retrospectively reviewed. Venous drainage was considered deep or superficial. Match of venous drainage pattern was defined as a superficial AVM with only superficial venous drainage or a deep AVM with deep venous drainage. Mismatch of venous drainage pattern was defined as a superficial AVM involving a deep venous drainage. Univariate analysis was used to assess the influence of match and mismatch of venous drainage pattern on AVM hemorrhagic presentation.
Results: AVM location and venous drainage were matched in 116 patients, including superficial location with superficial venous drainage or deep location with deep venous drainage, and were mismatched in 45 patients, including superficial location with deep venous drainage. The rupture proportion of mismatch venous drainage pattern was statistically comparable to that of deep location with deep drainage (P = 0.819). However, superficial location with deep venous drainage was statistically associated with a higher rupture percentage than that of superficial location with superficial venous drainage (P = 0.003).
Conclusions: Mismatch venous drainage pattern or an exclusively deep venous drainage is associated with an initial clinical presentation with an AVM hemorrhage.


Keywords: Arteriovenous malformation, hemorrhage, pattern, venous drainage
Key Message: Match of venous drainage pattern was defined as a superficial AVM with only superficial venous drainage or a deep AVM with deep venous drainage. Mismatch of venous drainage pattern was defined as a superficial AVM involving a deep venous drainage. The AVM rupture proportion of mismatch venous drainage pattern is comparable to that of a deep AVM with deep venous drainage. Mismatch of the venous drainage pattern.


How to cite this article:
Lv X, Yu J, Zhao X, Zhang H, Zhang X. Is there an Influence of Match and Mismatch of Venous Drainage Pattern on AVM Hemorrhagic Presentation?. Neurol India 2022;70:1590-2

How to cite this URL:
Lv X, Yu J, Zhao X, Zhang H, Zhang X. Is there an Influence of Match and Mismatch of Venous Drainage Pattern on AVM Hemorrhagic Presentation?. Neurol India [serial online] 2022 [cited 2022 Oct 2];70:1590-2. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1590/355081




Cerebral arteriovenous malformations (AVMs) are known to be a source of intracranial hemorrhage. Their natural history studies indicate approximately 2.4% to 4.6% annual hemorrhagic rates, which cause an annual mortality rate of 2.0%.[1],[2],[3] Hemorrhagic presentation has been described as a significant independent predictor for future hemorrhage, whereas exclusive deep venous drainage only shows a trend toward significance.[1],[2],[3],[4],[5] In some AVMs, superficial location nidus may be drained by deep veins. Will this mismatch of venous drainage pattern influence AVM natural history? A hypothesis that a superficial AVM draining deeply is certainly at higher risk than a deep AVM with deep venous drainage is promoted. Therefore, we performed this study to clarify this hypothesis.


 » Methods Top


Consecutive 161 patients of AVM between 2014 and 2017 were retrospectively reviewed. Patients ranged in age from 4 to 68 years, mean 28.5 ± 15.5 years. There were 82 male patients and 79 female patients. Initial AVM presentation was defined as rupture and unrupture. The size of AVM and the location of AVM were evaluated on MR imaging. The type of venous drainage was evaluated on digital subtraction angiography. The lesions were classified according to the Spetzler–Martin grade. AVM location included 2 categories: superficial and deep. A deep location was defined as ventricular nuclei, thalami, ventricles, and brain stem. A superficial AVM was defined as the surface of the cerebrum and cerebellum. Venous drainage was considered deep or superficial. Match of venous drainage pattern was defined as a superficial AVM with only superficial venous drainage [Figure 1] and [Figure 2] or a deep AVM with deep venous drainage. Mismatch of venous drainage pattern was defined as a superficial AVM involving deep venous drainage [Figure 3] and [Figure 4]. Approval from the ethics committee of our hospital is obtained in June, 2018.
Figure 1: (a) Right internal carotid artery injection showing a giant unruptured frontal AVM with a match of venous drainage pattern.(b) 2-year follow-up angiogram after Onyx embolization and gamma knife treatment showing nearly complete occlusion of the AVM

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Figure 2: (a) Left internal carotid artery angiogram, lateral view, showing a match of venous drainage pattern. (b) Control angiogram showing the AVM was completely embolized with Onyx. (c) Fluoroscopic image showing the Onyx cast

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Figure 3: (a) Left vertebral artery angiogram showing a ruptured AVM with mismatch of venous drainage pattern. (b) Control angiogram showing the AVM was completely embolized using Onyx

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Figure 4: (a) 3-D reconstruction of left internal carotid artery injection showing a AVM with mismatch of venous drainage pattern. (b) Control angiogram showing the AVM was completely embolized with Onyx. (c) Fluoroscopic image showing the Onyx cast

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Statistical analysis

T test and X2 test were used to analyze (with P < 0.05 being considered significant) including age, sex, presentation, and AVM grades between match and mismatch venous drainage patterns.


 » Results Top


Of the 161 AVMs, 93 (57.8%) were diagnosed because of intracranial hemorrhage. The remaining 68 (42.2%) AVMs had a non-hemorrhagic diagnostic event, such as seizure, headache, focal neurologic deficit, or other clinical events including incidental. [Table 1] summarizes the characteristics of AVMs with match and mismatch venous drainage patterns.
Table 1: Match and mis-match of venous drainage patterns of AVMs

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Fifty-one AVMs were of Spetzler–Martin grade I and II, 61 of grade III and 49 of grade IV to V. AVM location and venous drainage were matched in 116 patients, including 83 of superficial location with superficial venous drainage and 33 of deep location with deep venous drainage, and were mismatched in 45 patients, including superficial location with deep venous drainage. Forty-three (95.6%) of 45 AVMs of mismatched venous drainage patterns were Spetzler–Martin grade III to V.

In the univariate comparison, the AVM rupture proportion of mismatch venous drainage pattern was found to be comparable to that of a deep AVM with deep venous drainage (P = 0.819). However, a mismatch of the venous drainage pattern was more prone to rupture than a match of superficial venous drainage pattern (P = 0.003).


 » Discussion Top


The major complication of AVM is rupture and cause morbidity and mortality. AVM treatment is to decrease its hemorrhagic risk. The angioarchitecture of AVM rupture is very important for physicians making a treatment decision. This study found that the mismatch venous drainage pattern is not a predictor for AVM rupture. A superficial AVM with deep venous drainage was not more prone to rupture than a deep AVM with deep venous drainage, but a superficial AVM with deep venous drainage was more prone to rupture that a superficial AVM with superficial venous drainage. This meant that deep venous drainage plays a very important role in AVM rupture. A meta-analysis concluded that the prior hemorrhage, deep AVM location, exclusively deep venous drainage, and associated aneurysms were risk factors for hemorrhage.[6]

Exclusive deep venous drainage has been mentioned as a primary factor associated with hemorrhagic AVM presentation.[7],[8],[9],[10] The number of draining veins and periventricular venous drainage constructed logistic regression models did not demonstrate a lower hemorrhagic risk than the exclusively deep venous drainage. Stapf et al.[8] described that the relevant factors for hemorrhage manifestation were increasing age, deep AVM location, and exclusive deep venous drainage. In mismatch cases, AVM involves multiple superficial and deep compartments and associated with a high Spetzler–Martin grade, which was associated with hemorrhagic presentation of AVM and surgical challenge.[11],[12] Deep venous drainage may have a profound effect on AVM hemodynamics by promoting an increased pressure gradient across the vasculature of the nidus.[13] It is also possible that turbulent flow or elevated pressure in the deep venous system promotes platelet aggregation and venous thrombosis to cause AVM hemorrhage. The limitation of this study is merely observational and does not provide a longitudinal risk analysis.


 » Conclusions Top


Mismatch venous drainage pattern or an exclusively deep venous drainage is associated with an initial clinical presentation with an AVM hemorrhage.

Acknowledgement

This work was supported by Beijing Municiple Administration of Hospitals Incubating Program(PX2020039), Beijing, China & Tsinghua Precision Medicine Foundation(20219990008), Tsinghua University, Beijing, China. Approval from the ethics committee of our hospital is obtained in June, 2018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Laakso A, Dashti R, Seppänen J, Juvela S, Väärt K, Niemelä M, et al. Long-term excess mortality in 623 patients with brain arteriovenous malformations. Neurosurgery 2008;63:244-55.  Back to cited text no. 1
    
2.
da Costa L, Wallace MC, Ter Brugge KG, O'Kelly C, Willinsky RA, Tymianski M. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 2009;40:100-5.  Back to cited text no. 2
    
3.
Hernesniemi JA, Dashti R, Juvela S, Väärt K, Niemelä M, Laakso A. Natural history of brain arteriovenous malformations: A long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery 2008;63:823-31.  Back to cited text no. 3
    
4.
Shen X, Liu J, Lv X, Li Y. Risk of rupture and risks of endovascular management of unruptured brain arteriovenous malformations. Interv Neuroradiol 2014;20:495-501.  Back to cited text no. 4
    
5.
Yamada S, Takagi Y, Nozaki K, Kikuta K, Hashimoto N. Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations. J Neurosurg 2007;107:965-72.  Back to cited text no. 5
    
6.
Gross BA, Du R. Natural history of cerebral arteriovenous malformations: A meta-analysis. J Neurosurg 2013;118:437-43.  Back to cited text no. 6
    
7.
Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, et al. Risk Factors for subsequent hemorrhage in patients with cerebellar arteriovenous malformations. World Neurosurg 2016;92:47-57.  Back to cited text no. 7
    
8.
Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, et al. Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 2006;66:1350-5.  Back to cited text no. 8
    
9.
Duong DH, Young WL, Vang MC, Sciacca RR, Mast H, Koennecke HC, et al. Feeding artery pressure and venous drainage pattern are primary determinants of hemorrhage from cerebral arteriovenous malformations. Stroke 1998;29:1167-76.  Back to cited text no. 9
    
10.
Lv X, Wu Z, Jiang C, Yang X, Li Y, Sun Y, Zhang N. Angioarchitectural characteristics of brain arteriovenous malformations presenting with and without hemorrhage. World Neurosurg 2011;76:95-9.  Back to cited text no. 10
    
11.
Lv X, Hu X, Liu J, He H, Li Y. The influence of age and the initial clinical presentations of patients with an arteriovenous malformation on the risk of hemorrhage. Neurol India 2016;64(Suppl):S87-94.  Back to cited text no. 11
    
12.
Thapa A, Chandra PS, Sinha S, Gupta A, Singh M, Suri A, et al. Surgical interventions in intracranial arteriovenous malformations: Indications and outcome analysis in a changing scenario. Neurol India 2009;57:749-55.  Back to cited text no. 12
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13.
Kim BS, Sarma D, Lee SK, terBrugge KG. Brain edema associated with unruptured brain arteriovenous malformations. Neuroradiology 2009;51:327-35.  Back to cited text no. 13
    


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