Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS).</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0–2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.</jats:p></jats:sec>

Morbidity after Hemorrhage in Children with Untreated Brain Arteriovenous Malformation

“…In our pediatric cases, 42–46% of children were severely disabled after hemorrhagic presentation or subsequent hemorrhage, which is congruent with previous data of treated pediatric bAVM series (32–50%) [5, 6]. While some previous reports on bAVM patients of all ages suggested a lower rate of severe disability after incident hemorrhage (3–45%), however, a longer delay between bAVM rupture and neurological assessment might be one of the factors for the prevalence of lower rates in those studies (Table 4) [3, 18].…”

“…Additionally, treatment-free time after hemorrhage varies between individuals, further hindering the comparison of clinical outcome. A recent study indicated that although intervention would change bAVM prognosis, the long-term outcome was still correlated with neurological function at presentation [6]. In addition, neurological evaluation immediately after the index event was more likely to reveal the actual impact of hemorrhage after bAVM rupture [3].…”

Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations

“…1,15 In some instances, especially deep-seated and cortical eloquent lesions, surgery may carry excessive risks of morbidity, and less invasive methods are required. 1,2,13 Although SRS is often recommended, this technique needs a latency period of 2 to 3 years in which hemorrhage may occur. 3,11,16 Additionally, long-term effects of ionizing radiation in the developing brain are not fully determined, and the efficacy of SRS in high-flow arteriovenous fistulae is not well documented.…”

“…[1][2][3] In this age group, these lesions present an aggressive clinical course with higher rates of hemorrhage and mortality compared with adults. 3 Consequently, several publications have addressed that lifetime risks of critical intracranial hemorrhage in conjunction with the ability of the pediatric nervous system to recover from injury underscores risks of aggressive therapy.…”

High Grade Incidental Brain Arteriovenous Malformation

“…Nonetheless, a review of the ARUBA study is relevant, as its data reveal an annual stroke rate of approximately 4% for untreated AVMs [7].…”