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Background Previously thought to be congenital, AVMs have shown evidence of de-novo formation and continued growth, thus shifting thoughts on their pathophysiology. Pediatric AVM patients have been reported to be more prone to develop AVM recurrence after a seemingly complete cure. Therefore, we assessed the risk of AVM treated in childhood to recur in adulthood after a long-term follow-up in our own cohort. Methods Control DS-angiography was arranged during 2021–2022 as part of a new protocol for all AVM patients who were under 21 years of age at the time of their treatment and in whom the treatment had occurred at least five years earlier. Angiography was offered only to patients under 50 years of age at the time of the new protocol. The complete eradication of AVM after the primary treatment had been originally confirmed with DSA in every patient. Results A total of 42 patients participated in the late DSA control, and 41 of them were included in this analysis after excluding the patient diagnosed with HHT. The median age at the time of admission for AVM treatment was 14.6 (IQR 12–19, range 7–21 years) years. The median age at the time of the late follow-up DSA was 33.8 years (IQR 29.8–38.6, range 19.4–47.9 years). Two recurrent sporadic AVMs and one recurrent AVM in a patient with hereditary hemorrhagic telangiectasia (HHT) were detected. The recurrence rate was 4.9% for sporadic AVMs and 7.1% if HHT-AVM was included. All the recurrent AVMs had originally bled and been treated microsurgically. The patients with sporadic AVM recurrence had been smoking their whole adult lives. Conclusions Pediatric and adolescent patients are prone to develop recurrent AVMs, even after complete AVM obliteration verified by angiography. Therefore, imaging follow-up is recommended.

Background We wanted to understand how patients with different modified Rankin Scale (mRS) grades differ regarding their health-related quality of life (HRQoL) and how this affects the interpretation and dichotomization of the grade. Methods In 2016, all adult patients in our brain arteriovenous malformation (AVM) database ( n  = 432) were asked to fill in mailed letters including a questionnaire about self-sufficiency and lifestyle and the 15D HRQoL questionnaire. The follow-up mRS was defined in 2016 using the electronic patient registry and the questionnaire data. The 15D profiles of each mRS grade were compared to those of the general population and to each other, using ANCOVA with age and sex standardization. Results Patients in mRS 0 (mean 15D score = 0.954 ± 0.060) had significantly better HRQoL than the general population (mean = 0.927 ± 0.028), p  < 0.0001, whereas patients in mRS 1–4 had worse HRQoL than the general population, p  < 0.0001. Patients in mRS 1 (mean = 0.844 ± 0.100) and mRS 2 (mean = 0.838 ± 0.107) had a similar HRQoL. In the recently published AVM research, the most commonly used cut points for mRS dichotomization were between mRS 1 and 2 and between mRS 2 and 3. Conclusions Using 15D, we were able to find significant differences in the HRQoL between mRS 0 and mRS 1 AVM patients, against the recent findings on stroke patients using EQ-5D in their analyses. Although the dichotomization cut point is commonly set between mRS 1 and 2, patients in these grades had a similar HRQoL and a decreased ability to continue their premorbid lifestyle, in contrast to patients in mRS 0.

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Abstract BACKGROUND Population-based long-term data on pediatric patients with cerebral arteriovenous malformations (AVMs) are limited. OBJECTIVE To clarify the characteristics and long-term outcome of pediatric patients with AVM. METHODS A retrospective analysis was performed on 805 consecutive brain AVM patients admitted to a single center between 1942 and 2014. The patients were defined as children if they were under 18 yr at admission. Children were compared to an adult cohort. Changing patterns of presentation were also analyzed by decades of admission. RESULTS The patients comprised 127 children with a mean age of 12 yr. The mean follow-up time was 21 yr (range 0-62). Children presented more often with intracerebral hemorrhage (ICH) but less often with epilepsy than adults. Basal ganglia, cerebellar, and posterior paracallosal AVMs were more common in pediatric than in adult patients. Frontal and temporal AVMs, in contrast, were more common in adult than in pediatric patients. As the number of incidentally and epilepsy-diagnosed AVMs increased, ICH rates dropped in both cohorts. In total, 22 (82%) pediatric and 108 (39%) adult deaths were assessed as AVM related. After multivariate analysis, small AVM size and surgical treatment correlated with a favorable long-term outcome. CONCLUSION Hemorrhagic presentation was more common in children than in adults. This was also reflected as lower prevalence of epileptic presentation in the pediatric cohort. Lobar and cortical AVM locations were less frequent, whereas deep and cerebellar AVMs were more common in children. Hemorrhagic presentation correlated negatively with incidentally and epilepsy-diagnosed AVMs. In children, AVM was a major cause of death, but in adults, other factors contributed more commonly to mortality.

Abstract BACKGROUND A supplementary grading scale (Supplemented Spetzler-Martin grade, Supp-SM) was introduced in 2010 as a refinement of the SM system to improve preoperative risk prediction of brain arteriovenous malformations (AVMs). OBJECTIVE To determine the ability to predict surgical outcomes using the Supp-SM grading scale. METHODS This retrospective study was conducted on 200 patients admitted to the Helsinki University Hospital between 2000 and 2014. The validity of the Supp-SM and SM grading systems was compared using the area under the receiver operating characteristic (AUROC) curves, with respect to the change between preoperative and early (3-4 mo) as well as final postoperative modified Rankin Scale (mRS) scores. RESULTS The performance of the Supp-SM was superior to that of the SM grading scale in the early follow-up (3-4 mo): AUROC = 0.57 (95% confidence interval [CI]: 0.49-0.65) for SM and AUROC = 0.67 (95% CI: 0.60-0.75) for Supp-SM. The Supp-SM performance continued improving over SM at the late follow-up: AUROC = 0.63 (95% CI: 0.55-0.71) for SM and AUROC = 0.70 (95% CI: 0.62-0.77) for Supp-SM. The perforating artery supply, which is not part of either grading system, plays an important role in the early follow-up outcome (P = .008; odds ratio: 2.95; 95% CI: 1.32-6.55) and in the late follow-up outcome (P < .001; odds ratio: 5.89; 95% CI: 2.49-13.91). CONCLUSION The Supp-SM grading system improves the outcome prediction accuracy and is a feasible alternative to the SMS, even for series with higher proportion of high-grade AVMs. However, perforators play important role on the outcome.

Abstract BACKGROUND Research on the prevalence of smokers in patients with brain arteriovenous malformation (AVM) remains nonexistent, even though smoking is a well-known risk factor for intracranial aneurysms. OBJECTIVE To examine the prevalence and smoking habits of AVM patients. METHODS Data on smoking habits were collected with a quality-of-life questionnaire mailed in 2016 to all patients in our large AVM database. These smoking data were supplemented with registry data derived from medical records. The prevalence of smokers was compared to that of the general population, derived from statistics of National Institute for Health and Welfare. Logit transformation of proportions and Students t distribution were used to calculate the 95% CIs for prevalence estimates. RESULTS Of the 384 patients aged over 18 yr on admission, 277 (72.1%) returned the questionnaires in 2016. When compared to age, sex, and admission year matched general population, the proportion of smokers in AVM patients was 48% (CI = 41%-55%) and 19% (CI = 16%-21%) in the general population. The difference increased in older age groups; in those aged 65 to 77 yr, the percentage of smokers reached 73% (CI = 46%-90%), while the corresponding percentage in the general population was 7% (CI = 5%-9%). CONCLUSION We observed considerably higher rates of smoking among AVM patients when compared to age, sex, and admission year matched general population. Our results suggest that in the development of AVMs, the role played by nicotine and other substances in tobacco smoke should be examined. Cigarette smoking could potentially be a common cerebrovascular risk factor. Graphical Abstract Graphical Abstract

BackgroundDespite recent multi-institutional efforts, long-term data on clinical and radiological outcomes after treatment of high-grade dural arteriovenous fistulas (dAVFs) remain scarce. This study aimed to evaluate the long-term risk of hemorrhage and fistula-related mortality after treatment.MethodsRetrospective analysis of all consecutive patients primarily diagnosed with a high-grade dAVF (Cognard grade 2b, 2a+b, 3, 4) between January 2012 and September 2022 at a large neurovascular center. Primary endpoints were intracranial hemorrhage (ICH) and all-cause mortality after treatment; secondary endpoints were angiographic occlusion, complication rate and neurological deficits.ResultsA total of 121 patients underwent 141 treatments (122 endovascular therapy (EVT), 5 radiotherapy, 14 surgery) of which 12 patients (10%) underwent retreatment. Follow-up was available in all patients for a median of 4.2 (IQR 2.5 to 6.6) years. Eleven patients (9%) died during the follow-up period, of which three deaths (2%) occurred after hemorrhagic presentation, one of them attributable to treatment. One death (0.8%) was due to delayed hemorrhage after partial occlusion from EVT. No other post-treatment bleedings occurred. Angiographic follow-up after multimodality treatment was available in 93% of patients after a median of 6 months; the overall occlusion rate was 90%. The overall rate of complications was 25% after EVT and 14% after surgery. The rates of new transient and permanent neurological deficits after EVT were 9% and 3%, respectively.ConclusionsThe long-term rate of re-bleeding or dAVF-related mortality was low when high rates of angiographic occlusion were achieved. The risk for treatment-related complications leading to neurological sequela was low.

ObjectiveThe optimal timing of surgical intervention for chronic subdural hematomas (CSDH), specifically night-time versus daytime, remains a subject of debate, with concerns about the potential impact of circadian timing on surgical outcomes. This study evaluated the association between the timing of burr-hole drainage for CSDH and postoperative outcomes, comparing night-time and daytime surgeries.MethodsIn a post-hoc analysis of the FINISH trial, we included adult patients with symptomatic unilateral or bilateral CSDH who underwent burr-hole drainage between January 2020 and August 2022. Night-time surgery was defined as procedures starting between 23:00 and 06:00, with daytime surgeries occurring between 06:01 and 22:59. The primary outcome was functional outcome at six months post-surgery, assessed using the modified Rankin Scale (mRS), with favorable outcomes defined as an mRS of 0–3. Secondary outcomes included mortality, reoperation rates, and adverse events within six months.ResultsOur analysis of 589 patients (83% daytime surgery, 17% night-time surgery) revealed no significant differences in baseline characteristics. The unadjusted analysis suggested a higher rate of favorable functional outcomes in the night-time surgery group than in the daytime group (94% vs. 86%, p = 0.037). Mortality, adverse events, and reoperation rates were similar in the groups. Adjusted logistic regression analyses, accounting for potential confounders, indicated that night-time surgery was not associated with a higher risk of unfavorable functional outcomes compared to daytime surgery.ConclusionsOur findings suggest that night-time surgery versus daytime surgery is not associated with worse postoperative outcomes. These findings challenges the traditional preference for daytime CSDH surgery and emphasizes the potential for flexibility in surgical scheduling to optimize patient care in CSDH management.

Background There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome. Objective To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery. Methods We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2–4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome). Results Age over 40 years (OR 18.4; 95% CI 1.9–172.1; p  = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1–89.2; p  = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8–94.4; p  = 0.011), and over 400 cm 3 bleeding during surgery (OR 11.5; 95% CI 1.5–86.6; p  = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6–1524.9; p  = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4–829.9; p  = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6–332.6; p  = 0.007), and over 400 cm 3 bleeding during surgery (OR 35.3; 95% CI 1.7–748.7; p  = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2–55.7; p  = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3–24.3; p  = 0.019), and over 400 cm 3 bleeding during surgery (OR 5.8; 95% CI 1.2–27.3; p  = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome. Conclusions Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.