Correspondence

Arteriovenous Malformations of the Brain

N Engl J Med 2007; 357:1774-1775October 25, 2007

Article

To the Editor:

In his article on arteriovenous malformations of the brain, Friedlander (June 28 issue)1 cites an article that I coauthored to support the statement, “Some reports suggest that the risk of rupture of an arteriovenous malformation may be increased during pregnancy.” In fact, my coauthors and I arrived at the opposite conclusion.2 In a retrospective survey of 492 pregnancies in 216 women with unruptured arteriovenous malformation, we found no significant increase in the rate of hemorrhage during gestation. Keeping a firm grip on the data is important, because before our report, many women were told by their physicians that the risk of hemorrhage during pregnancy was prohibitive. As Friedlander points out, “A first hemorrhage most commonly occurs in patients between 20 and 40 years of age.” These are precisely the prime childbearing years. There is little evidence to suggest that an initial hemorrhage from arteriovenous malformation during pregnancy is anything more than a coincidence.

Jonathan C. Horton, M.D., Ph.D.
University of California at San Francisco, San Francisco, CA 94402
hortonj@vision.ucsf.edu

2 References

1. 1

   Friedlander RM. Arteriovenous malformations of the brain. N Engl J Med 2007;356:2704-2712
   Full Text | Web of Science | Medline

2. 2

   Horton JC, Chambers WA, Lyons SL, Adams RD, Kjellberg RN. Pregnancy and the risk of hemorrhage from cerebral arteriovenous malformations. Neurosurgery 1990;27:867-871
   CrossRef | Web of Science | Medline

Author/Editor Response

Horton correctly points to the conclusion from a study he coauthored stating that there is no apparent increase in the rate of hemorrhage of unruptured arteriovenous malformations during pregnancy. There is significant controversy among clinicians who manage arteriovenous malformations in pregnant patients, and it is for this reason that I placed this discussion in the Areas of Uncertainty section of my article. As stated in the last American Heart Association Scientific Statement on the management of brain arteriovenous malformations, “The data regarding AVM [arteriovenous malformation] hemorrhage risk during pregnancy are inconclusive.”1 Notwithstanding the controversy, I regret any confusion regarding the reference to the article by Horton et al.

Robert M. Friedlander, M.D.
Brigham and Women's Hospital, Boston, MA 02115
rfriedlander@rics.bwh.harvard.edu

1 References

1. 1

   Ogilvy CS, Stieg PE, Awad I, et al. AHA scientific statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 2001;32:1458-1471
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   A. Lorch, P. Albers, C. Winter, J. Beyer. (2011) Hochdosischemotherapie und Residualtumorresektion bei Patienten mit Hodentumor. Der Urologe 50:9, 1047-1054
   CrossRef

2. 2

   Masahiro Oikawa, Hideo Kuniba, Tatsuro Kondoh, Akira Kinoshita, Takeshi Nagayasu, Norio Niikawa, Koh-ichiro Yoshiura. (2010) Familial brain arteriovenous malformation maps to 5p13–q14, 15q11–q13 or 18p11: Linkage analysis with clipped fingernail DNA on high-density SNP array. European Journal of Medical Genetics 53:5, 244-249
   CrossRef

3. 3

   Takao Sekiya, Haruki Nishizawa, Naomi Ozawa, Shin Tada, Kiyoshi Hasegawa, Yutaka Hirota, Ryo-ichi Katoh, Tatsuo Ban-no, Yasuhiro Udagawa. (2009) Clinical features and characteristics of blood flow of uterine vascular abnormalities. Journal of Medical Ultrasonics 36:1, 19-26
   CrossRef