Recurrence of Pediatric Cerebral Arteriovenous Malformations after Angiographically Documented Resection

Abstract

Angiographically confirmed surgical resection is believed to be the ‘gold standard’ for cure in the treatment of intracranial arteriovenous malformations (AVMs). However, rare exceptions of recurrent AVMs have been documented. We are aware of 11 reported cases of recurrent AVMs in which complete resection of the initial lesion was confirmed by postoperative angiography. Eight of these cases were in the pediatric population. In this report, we present 2 additional cases of such recurrent lesions, review the clinical and scientific literature on this rare phenomenon and provide suggested management guidelines.

Postoperative imaging for detection of recurrent arteriovenous malformations in children

“…2,8,19 Only 18%-20% of patients with AVMs present before 15 years of age, 13,17 with hemorrhage and seizure being the most common primary events. 1,5,31,32 Treatment of AVMs includes microsurgical resection, radiosurgery, endovascular embolization, or a combination of these strategies. 3,6,24,28 Accumulating evidence has demonstrated that AVMs recur in children.…”

“…4,5 The annual risk of hemorrhage in pediatric AVM is approximately 3.2% per year, 17 with 5%-10% risk of death and up to 50% risk of neurological morbidity. 1,12,15,17 Early and complete treatment of these malformations in children is therefore important. Current treatment options include microsurgery, endovascular embolization, radiosurgery, or combined therapy.…”

“…1,2,9,10,16,23,29 Although the underlying cause of this apparently different biology is unclear, 26 it is an important factor to consider in the management and postoperative follow-up of pediatric patients with AVMs. In addition to patient age, deep venous drainage and diffuse nidus have been identified as potential risk factors for recurrence.…”

“…Some studies recommend imaging 6-12 months after a negative postoperative digital subtraction angiogram to rule out recurrent or residual AVM. 13,16,20,29 With reported cases of recurrence occurring 3 months to 16 years after primary treatment, 1,2,13,16,26,29 a more extended imaging protocol is likely necessary to capture recurrence and prevent associated morbidity. Follow-up imaging, however, carries additional risk, cost, and time.…”

Recurrent Cerebral Arteriovenous Malformation in a Child : Case Report and Review of the Literature

“…Complete excision or obliteration of the lesion usually eliminates the risks of hemorrhage, and a negative cerebral angiogram is generally considered indicative of a cure. Although recurrence of cerebral AVMs is rare, there are several reports of cerebral AVM recurrence in both children 1,2,4,[9][10][11] and adults 3,5,8,16) after complete resection verified by postoperative angiography.…”