Since 1984 we have been involved in the management of 30 children who had cardiac manifestations secondary to cerebrocranial arteriovenous shunts. Aneurysm malformation of the vein of Galen was the most common vascular lesion observed (73% of cases). In 77% of the patients the cardiac symptoms were the main presenting complaint. Medical treatment and/or endovascular therapy were indicated, depending on the age of the patients and the severity of the cardiac manifestations. Following embolization, the cardiac symptoms resolved (73%) or improved (18%) in 1 or 2 sessions. Mortality in the embolized group was 9%, and transient nonneurologic morbidity occurred in one case. Overall mortality, including four patients rejected for embolization, was 20%. These results compare favorably with medical and/or surgical management, alone or combined. The technique, challenges, indications and contraindications of endovascular therapy are discussed. Embolization represents an effective adjunct treatment to control, improve or cure the congestive cardiac manifestations caused by cerebrocranial arteriovenous shunts.

Anaesthesia combining isoflurane with a continuous infusion of remifentanil was significantly more effective than fentanyl at blunting responses to surgical stimuli. Significantly fewer patients responded to tracheal intubation with remifentanil at 0.4 microg kg(-1) min(-1), supporting the use of a higher initial infusion rate before intubation. Both remifentanil and fentanyl were well-tolerated, with reported adverse events typical of mu-opioid agonists.

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Background and objectiveThis open, multicentre study compared the ef®cacy and safety of remifentanil with fentanyl during balanced anaesthesia with 0.8% iso¯urane (end-tidal concentration) for major abdominal and gynaecological surgery, and the ef®cacy and safety of remifentanil for pain management in the immediate postoperative period. Methods Two-hundred and eighty-six patients were randomized to receive remifentanil 1 lg kg ±1 followed by 0.2 lg kg ±1 min ±1 (n 98), remifentanil 2 lg kg ±1 followed by 0.4 lg kg ±1 min ±1 (n 91) or fentanyl 3 lg kg ±1 (n 97) at induction. Thereafter, the study opioids and iso¯urane were titrated to effect during the operation. Results Compared with fentanyl, remifentanil 2 lg kg ±1 followed by 0.4 lg kg ±1 min ±1 reduced the incidence of response to tracheal intubation (30% vs. 13%, P < 0.01), skin incision (33% vs. 4%, P < 0.001) and skin closure (11% vs. 3%, P < 0.05), respectively. Patients receiving remifentanil 1 lg kg ±1 followed by 0.2 lg kg ±1 min ±1 had fewer responses to skin incision than the fentanyl group (12% vs. 33%, P < 0.001), but the incidences of response to tracheal intubation and skin closure were similar. Signi®cantly

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