AJR:215, August 2020 1 The Imaging Question What are the currently reported rates of treatment outcomes (i.e., complications, de- layed hemorrhage, obliteration rates, recur- rence rates, all-cause mortality, and neuro- logic status) after bAVM treatment and after conservative management in children? Background and Importance Brain arteriovenous malformations are vascular lesions formed from abnormal con- nections between arteries and veins in the brain, with a lack of capillaries between the vascular connections [4]. The goal of bAVM treatment is complete obliteration of the bAVM to prevent hemorrhage with preserva- Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis Parneyan Pezeshkpour 1 Adam A. Dmytriw 1 Kevin Phan 2 Manohar M. Shroff 1 Peter Dirks 3 Abhaya V. Kulkarni 3 Prakash Muthusami 1 Pezeshkpour P, Dmytriw AA, Phan K, et al. 1 Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada. Address correspondence to P. Muthusami (prakash.muthusami@sickkids.ca). 2 NeuroSpine Research Group, Liverpool Hospital, Sydney, Australia. 3 Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada. Pediatric Imaging • Best Practices/Original Research AJR 2020; 215:1–16 ISSN-L 0361–803X/20/2152–1 © American Roentgen Ray Society Clinical Vignette and Images In children, brain arteriovenous malfor- mations (bAVMs) are responsible for most cases of spontaneous intracranial hemor- rhage [1–3]. There is a limited but growing understanding regarding the long-term risk of hemorrhage as well as successful oblit- eration rates, case fatality, and complica- tion risk after different therapeutic inter- ventions or conservative management. In this systematic review and meta-analysis, we synthesize and summarize the avail- able evidence in the literature with an aim of providing practice guidelines to direct treatment decisions and to highlight re- search areas that need attention. Keywords: brain arteriovenous malformation, embolization, intracranial hemorrhage, pediatric arteriovenous malformation, radiosurgery doi.org/10.2214/AJR.19.22443 Received October 16, 2019; accepted after revision December 18, 2019. OBJECTIVE. The objective of this study was to assess the available evidence in the liter- ature regarding treatment outcomes for pediatric patients with brain arteriovenous malforma- tion (bAVM) with the aim of providing practice guidelines for treatment decisions and high- lighting research areas that need attention. MATERIALS AND METHODS. Keyword searches for studies published from Janu- ary 1, 1981, to April 16, 2018, were performed in MEDLINE, Embase, and Web of Science. Predefned inclusion criteria were used to identify studies. Poisson regression analysis for as- sociations between patient and bAVM characteristics and treatment outcomes. RESULTS. We identifed 34 articles comprising 2158 children with bAVM who under- went treatment or observation. The mean age of the study cohort was 12.0 ± 1.6 (SD) years, and 48.1% of the patients were female; 64.3% of bAVMs were hemorrhagic at presenta- tion. The mean follow-up was 50.6 ± 32.3 months. Overall, the meta-analysis of pooled data showed an obliteration rate of 69.8% (95% CI, 62.9–75.9%), recurrence rate of 2.2% (95% CI, 1.1–4.3%), and mortality rate of 2.4%. The pooled complication rate was 22.5% (95% CI, 15.7–31.1%) after surgery, 26.4% (95% CI, 15.2–41.9%) after embolization, and 27.1% (95% CI, 18.1–38.4%) after radiosurgery. Mortality was not associated with age, sex, or hemor - rhage; however, recurrence after treatment was inversely associated with age. Complication and mortality rates were reduced for multimodal treatments. For patients with bAVM treated with observation only, complication and mortality rates were 35.9% and 23.5%, respectively. CONCLUSION. Multimodality treatments for pediatric bAVM had lower mortality and complication rates than individual treatments. However, there is a lack of evidence for long- term outcomes. The mortality rate was highest in conservatively managed patients (i.e., ob- servation only). Further research directly comparing different treatment modalities for recur- rence and complications is warranted. Gathering data prospectively through multiinstitutional registries will be key to provide strong evidence. Pezeshkpour et al. Treatments and Outcomes of bAVMs in Children Pediatric Imaging Best Practices/Original Research Downloaded from www.ajronline.org by University of Toronto on 06/08/20 from IP address 142.150.190.39. Copyright ARRS. For personal use only; all rights reserved