Protection against future intracranial hemorrhage (ICH) is the primary reason to intervene surgically in patients harboring brain arteriovenous malformations (AVMs). Quantification of the competing risks of natural history and surgical treatment are needed to optimally inform safe and effective management. Our work in the last funding period identified genetic markers for spontaneous AVM ICH and has helped focus attention on the balance between treatment-related risks and those derived from leaving AVMs untreated. An important challenge and knowledge gap remains in how to best identify those patients who might benefit from surgical intervention, especially among those presenting with an unruptured AVM. Our preliminary data point to genetic risk markers for injury. The genes implicated act in inflammatory pathways, suggesting, for the first time, that there are commonalities between AVM risk and several other types of vascular disease. This project will provide needed biomarkers for risk assessment, and in so doing, help identify areas for parallel mechanistic studies. We propose the following specific aims:
Aim 1 will identify genetic markers that predict adverse outcome in AVM patients. In unruptured AVMs, Tumor Necrosis Factor-alpha (TNF-1) and Apolipoprotein-E (APOE) genotypes will predict risk of new hemorrhage in the untreated course. Further, Tumor Necrosis Factor-alpha (TNF-1) and Activin-like Kinase-1 (ALK-1) genotypes will predict functional decline after first (presenting) AVM hemorrhage.
Aim 2 examines Race- ethnicity influences on AVM hemorrhage risk, and we will show that Hispanics are at increased risk for AVM hemorrhage in the untreated course. We will evaluate race-ethnicity differences in time to new hemorrhage using self-report as well as genetic ancestry proportions determined by unlinked genetic markers, a novel application in cerebrovascular disease. Secondary analyses will include development of genetic markers to extend these methods to other racial/ethnic groups and to adjust for potential confounding.
Aim 3 will use Genome-wide Association Analysis (GWA) to identify novel genetic predictors of AVM hemorrhage using Affymetrix 500K GeneChip and further fine map significant regions to identify novel candidate genes associated with AVM hemorrhage.

Public Health Relevance

Brain arteriovenous malformations (AVMs) are an important cause of hemorrhagic stroke in young adults. Although surgical therapy can be curative, there are high costs and inherent morbidity and mortality associated with treatment that may outweigh the benefits, especially for patients with unruptured lesions. This project can provide biomarkers for risk stratification to aid rational choice of therapy to maximize benefit and minimize risk.

Agency
National Institute of Health (NIH)
Institute
National Institute of Neurological Disorders and Stroke (NINDS)
Type
Research Project (R01)
Project #
5R01NS034949-17
Application #
8300937
Study Section
Brain Injury and Neurovascular Pathologies Study Section (BINP)
Program Officer
Moy, Claudia S
Project Start
1995-09-30
Project End
2013-06-30
Budget Start
2012-07-01
Budget End
2013-06-30
Support Year
17
Fiscal Year
2012
Total Cost
$409,128
Indirect Cost
$144,320
Name
University of California San Francisco
Department
Anesthesiology
Type
Schools of Medicine
DUNS #
094878337
City
San Francisco
State
CA
Country
United States
Zip Code
94143
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Yu, Jay F; Nicholson, Andrew D; Nelson, Jeffrey et al. (2018) Predictors of intracranial hemorrhage volume and distribution in brain arteriovenous malformation. Interv Neuroradiol 24:183-188
LaHue, Sara C; Kim, Helen; Pawlikowska, Ludmila et al. (2018) Frequency and characteristics associated with inherited thrombophilia in patients with intracranial dural arteriovenous fistula. J Neurosurg :1-5
Winkler, Ethan A; Birk, Harjus; Burkhardt, Jan-Karl et al. (2018) Reductions in brain pericytes are associated with arteriovenous malformation vascular instability. J Neurosurg 129:1464-1474
Chen, Xiaolin; Cooke, Daniel L; Saloner, David et al. (2017) Higher Flow Is Present in Unruptured Arteriovenous Malformations With Silent Intralesional Microhemorrhages. Stroke 48:2881-2884
Ma, Li; Kim, Helen; Chen, Xiao-Lin et al. (2017) Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation. Cerebrovasc Dis 43:231-241
Weinsheimer, Shantel; Bendjilali, Nasrine; Nelson, Jeffrey et al. (2016) Genome-wide association study of sporadic brain arteriovenous malformations. J Neurol Neurosurg Psychiatry 87:916-23
Alexander, Matthew D; Cooke, Daniel L; Hallam, Danial K et al. (2016) Less can be more: Targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol 22:445-51
Pekmezci, Melike; Nelson, Jeffrey; Su, Hua et al. (2016) Morphometric characterization of brain arteriovenous malformations for clinical and radiological studies to identify silent intralesional microhemorrhages. Clin Neuropathol 35:114-21
Potts, Matthew B; Lau, Darryl; Abla, Adib A et al. (2015) Current surgical results with low-grade brain arteriovenous malformations. J Neurosurg 122:912-20

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