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Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia
  1. C L Shovlin1,4,
  2. J E Jackson5,
  3. K B Bamford2,6,
  4. I H Jenkins7,
  5. A R Benjamin4,
  6. H Ramadan4,
  7. E Kulinskaya3
  1. 1
    NHLI Cardiovascular Sciences, Faculty of Medicine, Imperial College London, UK
  2. 2
    Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College London, UK
  3. 3
    Statistical Advisory Service, Faculty of Medicine, Imperial College London, UK
  4. 4
    Department of Respiratory Medicine, Hammersmith Hospitals NHS Trust, London, UK
  5. 5
    Department of Imaging, Hammersmith Hospitals NHS Trust, London, UK
  6. 6
    Department of Microbiology, Hammersmith Hospitals NHS Trust, London, UK
  7. 7
    Department of Neurology, Hammersmith Hospitals NHS Trust, London, UK
  1. Dr C L Shovlin, NHLI Cardiovascular Sciences, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; c.shovlin{at}imperial.ac.uk

Abstract

Background: Brain abscesses and ischaemic strokes complicate pulmonary arteriovenous malformations (PAVMs). At risk individuals are poorly recognised. Stroke/abscess risk factors have not been defined.

Methods: A cohort study of 323 consecutive individuals with PAVMs (n = 219) and/or the commonly associated condition hereditary haemorrhagic telangiectasia (HHT, n = 305) was performed. Most of the 201 individuals with PAVMs and HHT had no respiratory symptoms, and were unaware they had HHT. Anderson–Gill models assessed constant and time dependent potential predictive variables for stroke/abscess, and rate reduction by PAVM embolisation.

Results: 57 individuals with PAVMs and HHT experienced brain abscess or ischaemic stroke, usually prior to the diagnosis of underlying PAVMs/HHT. The primary determinants of stroke and abscess risks were unrelated to severity of PAVMs. Males had higher brain abscess rates (hazard ratio 3.61 (95% CI 1.58, 8.25), p = 0.0024); interventional histories and bacteriological isolates suggested dental sources. Once adjusted for gender, there was a marginal association between brain abscess and low oxygen saturation. For ischaemic stroke, there was no association with any marker of PAVM severity, or with conventional neurovascular risk factors. Surprisingly, low mean pulmonary artery pressure was strongly associated with ischaemic stroke (hazard ratio 0.89 (95% CI 0.83, 0.95) per mm Hg increase; p = 6.2×10−5). PAVM embolisation significantly reduced ischaemic stroke rate (p = 0.028); no strokes/abscesses occurred following obliteration of all angiographically visible PAVMs. The mean PAVM diagnosis–treatment interval was longer, however, when neurological risks were unrecognised.

Conclusions: Ischaemic strokes and brain abscesses occur commonly in undiagnosed HHT patients with PAVMs. Risk reduction could be improved.

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Footnotes

  • Funding: This study received financial support from the Margaret Straker HHT Memorial Fund and other donations by families and friends of British HHT patients. We are grateful for support from the NIHR Biomedical Research Centre Funding Scheme. The funding sources played no part in the design, conduct or reporting of the study, nor in the decision to submit the paper for publication.

  • Competing interests: None.

  • Ethics approval: All studies were ethically approved by the Hammersmith, Queen Charlotte’s, Chelsea and Acton Hospital Research Ethics Committee (LREC 2000/5764).

  • Trial registration number: NCT00230685.

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