Rupture of arteriovenous malformations in three children with COVID-19 infection

Objective: To report 3 patients with arteriovenous malformation (AVM) rupture following SARS-Cov-2 infection. Background: There are increasing reports of neurological complications of COVID-19 infection. Manifestations of COVID-19 in children include a unique entity known as multisystem inflammatory syndrome (MISC). AVM size, location, venous drainage, and feeding artery patterns determine the risk of AVM rupture. We report three children with AVM rupture after COVID-19 infection and hypothesize an association. Design/Methods: We performed a retrospective review of 3 children with intracerebral hemorrhage secondary to AVM rupture presenting to a single center between May and July of 2020. Results: All 3 patients presented with abrupt neurological deterioration, 2 with altered mental status and one with gait instability. All were male and school aged (5, 6, 14 years). At least one high risk bleeding feature was present in each. In the case of the only posterior fossa AVM, a dysplastic varicosity of the draining vein was noted. In the child with a frontal AVM, there was an associated nidal aneurysm as well as deep venous drainage. In the third, the left temporal AVM was associated with a high-grade stenosis of the vein of Labbe. Two patients had positive nasopharyngeal SARS CoV2 Polymerase chain reaction (PCR). In these cases, inflammatory markers (ESR, CRP, d-dimer) were elevated as well as troponin 1. The patient with a negative COVID-19 nasopharyngeal PCR had a positive serum IgG titer. No inflammatory labs were sent in this case, but review of symptoms revealed he had a diffuse rash the week prior to presentation. Conclusions: AVM rupture in 3 COVID-19 positive patients at a single institution With in a span of 3 months appears significant enough to consider a possible association. We hypothesize that the inflammatory response to COVID-19 may alter AVM hemodynamic patterns and increases the risk for rupture.