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Background and Objective: Although randomized controlled trials have compared surgery versus endovascular treatment for intracranial aneurysms, the literature is sparse in terms of subgroup analysis for anterior communicating artery (ACoA) aneurysm management. This systematic review and meta-analysis sought to compare surgical versus endovascular treatment for ACoA aneurysms., Methods: Medline, PubMed, and Embase were searched from inception to December 12, 2022. Primary outcomes were post-treatment modified Rankin Scale (mRS) >2 and mortality. Secondary outcomes were aneurysm obliteration, retreatment and recurrence, rebleeding, technical failure, vessel rupture, aneurysmal subarachnoid hemorrhage-related hydrocephalus, symptomatic vasospasm, and stroke., Results: Eighteen studies yielded 2368 patients, from which 1196 (50.5%) and 1172 (49.4%) patients underwent surgery and endovascular treatment, respectively. The odds ratio (OR) of mortality was similar in total (OR = 0.92 [0.63-1.37], P = 0.69), ruptured (OR = 0.92 [0.62-1.36], P = 0.66), and unruptured cohorts (OR = 1.58 [0.06-39.60], P = 0.78). The OR of mRS > 2 was similar in total (OR = 0.75 [0.50-1.13], P = 0.17), ruptured (OR = 0.77 [0.49-1.20], P = 0.25), and unruptured cohorts (OR = 0.64 [0.21-1.96], P = 0.44). The OR of obliteration was higher with surgery in the total (OR = 2.52 [1.49-4.27], P = 0.0008) and ruptured cohorts (OR = 2.61 [1.33-5.10], P = 0.005) and unruptured group (OR = 3.46 [1.30-9.20], P = 0.01). The OR of retreatment was lower with surgery in the total (OR = 0.37 [0.17-0.76], P = 0.007) and ruptured cohorts (OR = 0.31 [0.11-0.89], P = 0.03), thought it was similar in the unruptured group (OR = 0.51 [0.08-3.03], P = 0.46). The OR of recurrence was lower with surgery in the total (OR = 0.22 [0.10, 0.47], P = 0.0001), ruptured (OR = 0.16 [0.03, 0.90], P = 0.04), and mixed (un) ruptured cohorts (OR = 0.22 [0.09-0.53], P = 0.0009). The OR of rebleeding in ruptured group was similar (OR = 0.66 [0.29-1.52], P = 0.33). The ORs of other outcomes were similar., Conclusions: ACoA aneurysms may be safely treated with either surgery or endovascular treatment, although microsurgical clipping demonstrates higher obliteration rates and lower rates of retreatment and recurrence., (Published by Elsevier Inc.)

Background: Randomized controlled trials comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous thrombolysis (EVT + IVT) for acute ischemic stroke due to large artery occlusion remain controversial. This systematic review and meta-analysis seek to compare these 2 modalities., Methods: Online Protocol is available at PROSPERO (york.ac.uk) (registration# CRD42022357506). MEDLINE, PubMed, and Embase were searched. The primary outcome was 90-day modified Rankin scale (mRS) ≤2. Secondary outcomes were 90-day mRS ≤1, 90-day mean mRS, National Institutes of Health Stroke Scale (NIHSS) at 1-3 and 3-7 days, 90-day Barthel Index, 90-day EQ-5D-5L (EuroQoL Group 5-Dimension 5-Level), the volume of infarction (mL), successful reperfusion, complete reperfusion, recanalization, 90-day mortality, any intracranial hemorrhage (ICH), symptomatic ICH, embolization in new territory, new infarction, puncture site complications, vessel dissection, and contrast extravasation. The certainty in the evidence was determined by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach., Results: Six randomized controlled trials yielding 2332 patients were included, of which 1163 and 1169 underwent EVT and EVT + IVT, respectively. The relative risk (RR) of 90-day mRS ≤2 was similar between the groups (RR = 0.96[0.88, 1.04]; P = 0.28). EVT was non-inferior to EVT + IVT because the lower bond of 95% confidence interval of the risk difference (RD = -0.02 [-0.06, 0.02]; P = 0.36) exceeded the -0.1 non-inferiority margin. The certainty in the evidence was high. The RR of successful reperfusion (RR = 0.96 [0.93, 0.99]; P = 0.006), any ICH (RR = 0.87 [0.77, 0.98]; P = 0.02), and puncture site complications (RR = 0.47 [0.25, 0.88]; P = 0.02) were lower with EVT. For EVT + IVT, the number needed to treat for successful reperfusion was 25, and the number needed to harm for any ICH was 20. The 2 groups were similar in other outcomes., Conclusion: EVT is non-inferior to EVT + IVT. In centers capable of both EVT and IVT, if timely EVT is feasible, it is reasonable to skip bridging IVT and keep rescue thrombolysis at the discretion of the interventionist for patients presenting within 4.5 hours of anterior ischemic stroke., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Flow diversion is increasingly used for off-label treatments of distal circulation aneurysms. Reports of use in sub-2.0-mm vessels are scant., Methods: A prospectively collected, institutional review board-approved cerebral aneurysm database was reviewed to identify patients who underwent flow diversion with a 2.5-mm diameter Pipeline embolization device., Results: Sixty-seven aneurysms were treated in 67 procedures (66 [99%] successful, 64 [96%] single device, 2 [3%] with 2 devices) in 57 patients. Average age was 56 years and 60% were female. Aneurysm location was 51 (76%) anterior cerebral artery, 14 (21%) middle cerebral artery, and 2 (3%) posterior cerebral artery. Aneurysm size was 4.1 ± 3.0 mm (1-20 mm). Safety outcomes included 3 major strokes (4.5%) resulting in permanent neurologic deficit (modified Rankin Scale score 6,4,4), including 1 mortality (1.5%). Acute stent thrombosis was observed intraprocedurally or within 24 hours of each stroke. There were 2 small-volume (<10 cm 3 , 40 cm 3 ) dependent intracerebral hemorrhage (3.0%) that resolved without permanent neurologic deficit. For effectiveness, 71% of patients underwent follow-up angiography. Complete occlusion was achieved by 88% at 6 months, 86% at 12 months, and 89% at last follow-up. A slight vessel diameter reduction was apparent on average 6.9 months after the procedure, which was statistically significant at the proximal (P = 0.001) but not distal (P = 0.317) device end. Preoperative average parent vessel diameter was 1.9 mm proximally (range, 1.1-2.6 mm) and 1.7 mm distally (range, 1.0-2.3 mm) of the Pipeline embolization device. Follow-up average vessel diameter was 1.7 mm proximally (range, 0.7-2.4 mm) and 1.6 mm distally (range, 0.6-2.1 mm). Flow delay associated with vessel diameter reduction occurred once. There were no cases of asymptomatic vessel occlusion., Conclusions: Flow diversion can be safe and effective for aneurysms originating from vessels <2.0 mm in diameter. Heightened vigilance for the prevention and management of acute stent and vessel thrombosis is warranted in these cases., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The risk of hemorrhage remains after radiosurgery for patients with arteriovenous malformations (AVMs), especially during the latency period. The effect of venous outflow stenosis on postradiosurgery AVM hemorrhage has been understudied. The present study sought to clarify the effect of venous stenosis on postradiation hemorrhage., Methods: We retrospectively reviewed the records of patients with AVM seen at our institution from 1990 to 2015. Patients who had undergone radiosurgery were included, and those without sufficient data were excluded. We performed multivariable Cox regression to evaluate the predictors of postradiosurgery hemorrhage, with specific emphasis on venous stenosis. Patients were censored from the first radiosurgery to hemorrhage or the last follow-up visit. The baseline and angiographic characteristics were compared between those with venous stenosis and those without to address potential confounders., Results: The present study included 240 patients, of whom 29 (12.1%) had venous stenosis. The venous stenosis cohort included more patients with venous varices (P = 0.009) and fewer with deep venous drainage (P = 0.048) compared with those without venous stenosis. Most patients had grade III or higher AVMs (63.2%), with an obliteration rate of 32.9%. In an all-inclusive multivariable Cox regression, hemorrhage risk was associated with venous stenosis (hazard ratio [HR], 3.70; P = 0.034), age (HR, 1.05; P = 0.002), AVM volume (HR, 1.04; P = 0.004), and hemorrhage before treatment (HR, 4.11; P = 0.014). Male gender was protective (HR, 0.31; P = 0.036) against hemorrhage., Conclusions: We identified statistically significant risk factors for postradiosurgery AVM hemorrhage, which included advanced age, female gender, the presence of venous stenosis, a larger AVM volume, and previous hemorrhage. We recommend cautious selection of patients for radiosurgery with close follow-up after treatment, especially for patients with these risk factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Few reports have compared surgical intervention with conservative treatment for moyamoya disease (MMD) in non-Asian cohorts. This study describes the effectiveness of follow-up stroke prevention by indirect revascularization relative to conservative management in a Northeast United States study population., Method: We retrospectively reviewed records of patients with MMD at our institution from 1990 to 2014. Baseline characteristics and follow-up results including subsequent ipsilateral strokes were collected, and compared between an indirect revascularization group and a conservatively treated group on a per-hemisphere basis., Results: A total of 94 patients with 184 hemispheres were included. The average age was 23.9 ± 18.1 years, with 76.6% (n = 141) being female. Racial distribution comprised white (n = 75, 40.8%), African-American (n = 57, 31.0%), Asian (n = 30, 16.3%), and other (n = 22, 12.0%). Eighty-three hemispheres (45.1%) presented with ipsilateral stroke and 54 (29.3%) with ipsilateral TIA. Management strategies included either conservative management (51.1%) or indirect bypass (48.9%). Patients who were male (P < 0.001), on baseline antiplatelets (P = 0.043), or with speech disturbance (P = 0.002) were more likely to receive indirect revascularization. Patients with headache history were more likely to be treated conservatively (P = 0.046). History of ipsilateral stroke was borderline associated with indirect bypass (P = 0.058). During a follow-up period of 6.37 ± 5.81 years, the annual risk of stroke for indirect revascularization group was 0.93% and 2.70% for the conservative group. Multivariate analysis found that increasing age (P = 0.029), posterior cerebral artery involvement (P = 0.040), and conservative treatment (P = 0.048) were associated with follow-up stroke., Conclusion: Our results suggests that indirect revascularization provides symptom relief and lower risk of stroke during follow-up compared with conservative management. Indirect revascularization should be considered for symptomatic MMD patients with a low surgical risk profile in a similar patient population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Preoperative embolization is established as an advantageous adjunct in multimodality treatment of cerebral arteriovenous malformations (AVMs). However, the benefit of preoperative embolization in AVMs with favorable surgical risk profile is debatable, because it has yet to be supported by evidence in comparative studies. In this study, we assessed outcome of surgically treated patients in a comparative setting., Methods: Our institutional AVM database of retrospectively and prospectively collected data between 1990 and 2015 was reviewed. Patients with complete clinical data who underwent surgical resection for AVMs were included. We performed a 1:1 ratio propensity score match for baseline variables that differed between patients with or without preoperative embolization. Differences in surgical risk and outcomes were evaluated between these 2 groups., Results: AVM size, eloquence, deep drainage, middle cerebral artery feeder, and ruptured presentation differed significantly between the 2 groups. Forty-eight patients without preoperative embolization were matched to 48 with embolization, with no significant differences in baseline variables or AVM characteristics between the 2 groups. We found no significant differences in AVM obliteration and postoperative modified Rankin Scale (mRS) score between embolized and nonembolized patients, respectively. Change in mRS score from preoperative score was also not significant, although more embolized patients had a decline in mRS score. Secondary outcome measures including duration of surgery (P = 0.172), intraoperative bleeding (P = 0.280), duration of hospitalization (P = 0.368), and postoperative symptoms were also similar between both groups., Conclusions: Our data do not support substantial benefit of preoperative embolization for patients with a favorable surgical risk profile. Because of risks and costs with this intervention, the prudent use of preoperative embolization should be individually considered., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The current study describes the impact of surgery in preventing follow-up ipsilateral transient ischemic attacks (TIAs)/strokes in an East Coast North American cohort of patients with both moyamoya syndrome (MMS) and neurofibromatosis type 1 (NF1) (MMS-NF1)., Methods: We retrospectively reviewed records of patients with MMS and NF1 at the Johns Hopkins Medical Institutions from 1990-2014. Baseline characteristics and follow-up results including subsequent ipsilateral strokes were collected and compared between a revascularization group (group 1) and a conservatively managed group (group 2) on a per-hemisphere basis., Results: A total of 9 patients (14 hemispheres) were included in our study. The average age of all patients at NF1 diagnosis was 2.1 ± 7.7 years, with 6 being female (66.7%). The average age of all patients at MMS diagnosis was 10.4 ± 16.6 years with the median age being 7.7 years (range: 4.1-27.0 years). Race distribution was: White (n = 4, 44.4%), Black (n = 3, 33.3%), and Asian (n = 2, 22.2%). Four patients (44.5%) experienced cerebrovascular manifestations of MMS before MMS diagnosis. Group 1 was younger at MMS diagnosis (P = 0.009), likely with a more acute symptom onset (P = 0.077). Management strategies were: pial synangiosis (n = 3, 21.4%) and conservative (n = 11, 78.6%). During an average follow-up period of 6.28 ± 2.0 years, no ipsilateral TIAs/strokes were observed for group 1; conversely, 2 ipsilateral TIAs (18.2%) and 2 ipsilateral strokes (18.2%) occurred in group 2., Conclusions: In our study of non-Asian patients with MMS-NF1, revascularization reduced stroke recurrence and deterioration of symptoms. However, more studies are warranted to further explore the role of revascularization procedures given the rarity of this disease combination., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Arteriovenous malformation (AVM) diffuseness has been shown to be prognostic of treatment outcomes. We assessed interobserver agreement of AVM diffuseness among physicians of different specialty and training backgrounds using digital subtraction angiography (DSA)., Methods: All research protocols were approved by the institutional review board for this retrospective chart review. In a single-blinded setting, 2 attending neurosurgeons, 1 attending interventional neuroradiologist, and 1 senior neurosurgical resident rated 80 DSA views of 36 AVMs as either compact or diffuse. Individual interobserver agreement and subgroup agreement were analyzed using κ agreement and intraclass correlation coefficient., Results: Disagreement regarding AVM diffuseness occurred in 43.8% of all DSA views (n = 80). Interobserver κ agreement on AVM diffuseness using DSA views among 4 physicians ranged from fair (κ = 0.40 [95% confidence interval (CI) = 0.22-0.58]) to substantial (κ = 0.65 [95% CI = 0.48-0.81]), whereas total intraclass correlation coefficient was 0.81 (95% CI = 0.73-0.87). For the 36 AVMs, κ agreement ranged from fair (κ = 0.36 [95% CI = 0.13-0.60]) to moderate (κ = 0.57 [95% CI = 0.35-0.79]), whereas intraclass correlation coefficient among all 4 physicians was 0.68 (95% CI = 0.47-0.82). Moderate agreement on AVM diffuseness (n = 80) was found between attending and resident assessments (κ = 0.57 [95% CI = 0.39-0.75]) and between neurosurgeon and interventional neuroradiologist assessments (κ = 0.55 [95% CI = 0.37-0.73])., Conclusions: Agreement of individual physicians on AVM diffuseness varies from fair to substantial. Objective and three-dimensional measures of AVM diffuseness should be developed for consistent clinical application., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Management decisions for brainstem arteriovenous malformations (AVMs) are complicated by balancing the risks of treatment and natural progression to hemorrhage. The present study seeks to compare radiosurgery and conservative management outcomes in brainstem AVMs., Methods: We performed a retrospective review of patients with brainstem AVM seen at our institution from 1990 to 2013. Patients missing baseline information or those lost to follow-up were excluded. Clinical and angiographic characteristics and subsequent hemorrhagic risk were evaluated according to brainstem AVM location and treatment modality., Results: We identified 30 patients with brainstem AVM with complete data. Mean age was 41.6 ± 20.3 years, and 53.3% (n = 16) were male. Sixteen (53.3%) presented with hemorrhage. Twelve patients (40.0%) were conservatively managed, and 18 were treated. Sixteen (88.9%) of the treated patients underwent radiosurgery, 1 (5.6%) underwent surgery, and 1 (5.6%) underwent embolization only. Average follow-up period was 4.7 ± 5.7 years, and 5 patients (16.7%) experienced recurrent hemorrhage, 3 of whom were in the radiosurgery group and 2 in the conservative group, giving an annual recurrent hemorrhage risk of 3.7% and 4.8%, respectively. Lesion obliteration was achieved in 8 patients (26.7%). Baseline clinical and angiographic factors were similar between the radiosurgery and conservative group. Obliteration was achieved in 43.8% of those treated with radiosurgery (P = 0.008). Despite similar baseline modified Rankin Scale scores, more patients had improvement of modified Rankin Scale score at last follow-up in the radiosurgery group (P = 0.004). Recurrent hemorrhage during follow-up was similar between the 2 groups (P = 0.887)., Conclusions: Our results suggest that when patients with brainstem AVM are selected cautiously, radiosurgery may achieve obliteration and symptom relief without increasing subsequent hemorrhage risk., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The safety of carotid revascularization in patients with concomitant extracranial carotid stenosis and cerebral aneurysm is rarely reported. We examine the risk of subarachnoid hemorrhage, aneurysm growth, ipsilateral transient ischemic attack, or stroke after revascularization in patients with both carotid stenosis and cerebral aneurysms., Methods: A retrospective cohort study of patients with concomitant diagnosis of aneurysm and carotid stenosis evaluated in the neurosurgical department at our institution from 1990 to 2013 was carried out. Patients with both revascularized and nonrevascularized carotid stenosis were included. Demographic and angiographic characteristics, medical history, and treatment outcomes were collected. Comparison was made between the following 2 groups: revascularized carotid stenosis with stent or carotid endarterectomy versus nonrevascularized carotid stenosis., Results: The study cohort consisted of 39 patients with 48 stenotic cervical internal carotid arteries and 51 cerebral aneurysms. Twenty patients (51.3%) underwent carotid endarterectomy/stenting, and 19 (48.7%) were managed medically. Patient characteristics were similar across the 2 groups except for increased severity of carotid stenosis (P < 0.001) and more posterior circulation aneurysms (P = 0.045) in the revascularized group. Ipsilateral stenosis and aneurysm was observed in 9 cases (40.9%) in the revascularized group and in 11 cases (42.3%) in the nonrevascularized group. During average follow-up of 1.62 years, no aneurysm rupture was observed. One ipsilateral stroke occurred in the revascularized group during follow-up, corresponding to an annual risk of 2.0%. One aneurysm enlargement occurred per group, with both located in the posterior circulation., Conclusions: Our study suggests that revascularization procedures for carotid stenosis should be considered safe and effective in patients with concomitant extracranial carotid occlusive disease and cerebral aneurysms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Patients undergoing carotid endarterectomy (CEA) are at risk of developing ipsilateral stroke or transient ischemic attacks (TIAs). In this study, we explored factors associated with development of these events following CEA in patients with long-term follow-up., Methods: We performed a retrospective analysis of all neurosurgical patients who underwent CEA and presented with ipsilateral ischemic stroke, TIA, or amaurosis fugax. Factors were compared against the outcome variable in univariate analysis. Multivariate logistic regression model was used to identify independent predictive variables. We used Kaplan-Meier analysis (log-rank test) to compare the effect of variables on long-term event-free survival., Results: Our study included 270 patients with an average age of 67.2 years. Two-hundred and forty-nine patients within our study cohort (92.2%) with 273 CEAs were followed at our institution. At presentation, 187 patients (68.5%) were symptomatic. The average follow-up was 50.2 months (113.2 lesion-years). Event-free survival was 91.6% and 89.9% at 2 years and 5 years, respectively. Family history of stroke (P = 0.002), cigarette smoking (P = 0.021), and atrial fibrillation (P = 0.005) significantly increased the risk of adverse events, whereas symptomatic presentation demonstrated a trend toward significance (P = 0.057). A higher risk for ischemic events was observed in female patients as compared with males with asymptomatic presentation (P = 0.005)., Conclusions: Our data suggest that family history of stroke, cigarette smoking, and atrial fibrillation are independent risk factors for developing ischemic events after CEA. In patients with asymptomatic presentation, female gender is also a risk factor. Identification of patients at risk is critical for tailored postoperative patient management and patient education., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Restenosis after carotid endarterectomy (CEA) is a potential complication after surgery for carotid stenosis. Stroke after CEA is a debilitating complication secondary to restenosis, and modification of postoperative care may be necessary to decrease the incidence of postoperative stroke after CEA. We sought to identify the clinical and patient factors that are associated with this complication., Methods: A retrospective analysis of all neurosurgical patients who underwent CEA for symptomatic or asymptomatic carotid stenosis was performed. Factors were compared against the outcome variable in a univariate analysis. A multivariate logistic regression model was used to identify independent predictive variables. We used Kaplan-Meier analysis to compare the effect of the variables on long-term event-free survival., Results: A total of 273 CEA procedures and their outcomes were analyzed with a mean follow-up of 50.7 months. Twenty-one patients had restenosis (7.6%). Rates of restenosis and restenosis-free survival were analyzed with Kaplan-Meier curves (log-rank test). In the multivariate model, a family history of stroke was the only variable that was significantly associated with restenosis after CEA., Conclusions: Our findings suggest that a family history of stroke is an important factor that predisposes patients to restenosis after CEA. Restenosis-free survival is influenced by the presence of hyperlipidemia, age, and family history of stroke. Closer surveillance with more frequent follow-up and multidisciplinary management may be beneficial in patients who have these risk factors to prevent restenosis and prolong restenosis-free survival., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The risk of delayed hemorrhage occurring greater than 2 years after treatment in brain arteriovenous malformations (AVMs) rarely is reported. In this study, we compare the risk of delayed hemorrhage across different treatment modalities., Methods: We performed a retrospective chart review of treated patients with a single intracranial AVM seen at our institution from 1990 to 2013. Delayed hemorrhage was defined as hemorrhage occurring at least 2 years after last treatment. Survival analysis was used to assess risk of delayed hemorrhage by treatment modalities., Results: Our study included 420 patients. Spetzler-Martin grades were as follows: I (12.6%), II (36.2%), III (32.6%), IV (15.0%), and V (3.6%). Average follow-up time is 5.1 years. Twenty-two patients (5.2%) were found to have 28 delayed hemorrhages. Average interval between last treatment and delayed hemorrhage was 7.6 years, with the longest being 24.2 years. Proportions of delayed hemorrhages by treatment modalities were as follows: surgery ± embolization (group I, 9.1%), radiosurgery ± embolization (group II, 63.6%), embolization only (group III, 22.7%), and surgery + radiosurgery ± embolization (group IV, 4.5%). Annualized hemorrhage risk after 2 years for each treatment group was as follows: group I (0.4%), group II (1.2%), group III (3.7%), and group IV (1.7%). Survival analysis demonstrated lowest risk of delayed hemorrhage for group 1 (P < 0.01)., Conclusions: This study is the first to compare the risk of delayed hemorrhage across different treatment modalities. Surgical resection is associated with the lowest risk for delayed hemorrhage compared with other treatment modalities. Patients with partially embolized AVMs should seek timely definitive treatment to decrease the risk of delayed hemorrhage., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Studies focusing on hemorrhagic presentation of brain arteriovenous malformations (AVMs) have largely limited their analysis to angiographic features. We report the importance of race/ethnicity as a clinical factor associated with hemorrhagic AVM presentation in addition to previously reported angiographic features., Methods: Data were prospectively and retrospectively collected on patients (N = 194) during the period 1993-2010 who presented with a single intracranial AVM, and baseline characteristics were compared for hemorrhagic presentation versus nonhemorrhagic presentation. Features that were statistically significant in univariate analysis or clinically significant were included in a multivariate analysis., Results: The median age at presentation was 32 years; 37.2% of patients were male. Spetzler-Martin grades were I in 17.5%, II in 37.1%, III in 28.9%, IV in 14.9%, and V in 1.5%. Baseline characteristics that differed significantly between patients presenting with hemorrhage compared with patients without hemorrhage were the following: race (P < 0.01), AVM size (P < 0.01), <3 feeding arteries (P = 0.01), absence of middle cerebral artery supply to AVM (P < 0.01), and AVM location (P < 0.01). Multivariate analysis revealed nonwhite race (odds ratio [OR] = 3.09 [95% confidence interval (CI) = 1.52, 6.44], P < 0.01); smaller AVM size (OR = 0.65 [95% CI = 0.19, 0.86], P < 0.01); and nonfrontal lobar (OR = 2.61 [95% CI = 1.2, 5.59], P = 0.02), basal ganglia (OR = 6.20 [95% CI = 1.52, 26.26], P = 0.01), or brainstem locations (OR = 4.41 [95% CI = 1.38, 14.92], P = 0.01) as factors associated with hemorrhagic presentation of brain AVMs., Conclusions: To our knowledge, this is the first study demonstrating that race/ethnicity is significantly associated with hemorrhagic presentation of AVMs. We also confirmed previous observations that AVM size and location are associated with hemorrhagic presentation., (Copyright © 2015 Elsevier Inc. All rights reserved.)