Superior outcomes in children compared with adults after microsurgical resection of brain arteriovenous malformations

Sanchez-Mejia, René O.; Chennupati, S.K.; Gupta, Nalin; Fullerton, Heather J.; Young, William L.; Lawton, Michael T.

doi:10.3171/ped.2006.105.2.82

Cited by 64 publications

(57 citation statements)

References 12 publications

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“…1,3,5,6,20,25,28,30,34,40 By comparison, reports of surgical AVM series, summarized in Table 7, 2,5,8,9,[16][17][18]21,22,27,31 are sparse and contain fewer patients, but some describe better results after resection of AVMs in children than in adults. 31 Furthermore, as most pediatric AVMs in nearly all series are hemorrhagic, 2,8,9,16-18,22 a more aggressive, expedient therapy via microsurgery, as opposed to radiosurgery, should be sought in such cases. It is interesting to note that in the most recent iteration of radiosurgical grading schemes, hemorrhage was considered an adverse factor for radiosurgical success, 38 an assessment that differs from the observed impact of hemorrhage on the outcomes of microsurgery.…”

Section: Patient Selectionmentioning

confidence: 99%

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

Gross¹,

Storey²,

Orbach³

et al. 2015

PED

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OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS 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). RESULTS 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%. CONCLUSIONS 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.

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Section: Patient Selectionmentioning

confidence: 99%

“…Reports of treatment outcome in moderate-to large-size pediatric cohorts are rare. 2,5,16,18,22,27,31 We reviewed our own surgical experience with AVMs to elucidate obliteration rates and treatment results in the context of an evolved institutional protocol. …”

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confidence: 99%

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

Gross¹,

Storey²,

Orbach³

et al. 2015

PED

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“…Complete resection rates are all high in the published series, ranging from 80% to 100%. 5,9,13,16,21 We believe the use of intraoperative ultrasound in combination with neuronavigation and integrated operative microscopy is a safe and reliable technique to aid AVM resection in pediatric patients. There are clear advantages in being able to position a smaller craniotomy directly over the intended target lesion: it minimizes blood loss from the craniotomy site and reduces incision length.…”

Section: Discussionmentioning

confidence: 99%

“…13,[16][17][18] Arteriovenous malformations in the pediatric population have generally been associated with higher morbidity and mortality than those in adults, 11,18 although a recent study suggests that surgery may improve long-term outcomes. 21 There is also a well-described phenomenon of AVM recurrence following negative postresection angiography in the pediatric population. 7,11,18 Nonetheless, pediatric AVMs have been treated surgically, with endovascular embolization, with radiosurgery, and increasingly with multimodality treatments with good results.…”

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confidence: 99%

Use of intraoperative Doppler ultrasound with neuronavigation to guide arteriovenous malformation resection: a pediatric case series

Walkden¹,

Zádor²,

Herwadkar³

et al. 2015

PED

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OBJECT Over the last 20 years, several intraoperative adjuncts, including ultrasonography, neuronavigation, and angiography, have been said to aid the intraoperative localization and resection of cerebral arteriovenous malformations (AVMs). The authors assessed the value of intraoperative Doppler ultrasonography in conjunction with neuronavigation during surgery for cerebral AVMs in the pediatric population. METHODS The authors reviewed all cranial AVM resections performed by a single surgeon at their institution in the period from 2007 to 2013 and here describe their experience and results in a series of 20 consecutive AVM resections in 19 pediatric patients. Intraoperative Doppler ultrasonography had been used in conjunction with preoperative CT or neuronavigational MRI. Preoperative and postoperative clinical findings, patient age, and Spetzler-Martin AVM grade were identified in all patients. RESULTS All patients, whose ages ranged from 2 to 16 years, underwent craniotomy and excision of an AVM, which was supratentorial in 18 cases and infratentorial in 2. Patients in 11 cases underwent preoperative embolization, and all other patients underwent cerebral angiography prior to surgery, except for 2 patients who were urgently surgically treated because of low Glasgow Coma Scale scores and associated hematoma. Spetzler-Martin Grades I (3 cases), II (6), III (7), and IV (4) AVMs were represented in this series. Intraoperative Doppler ultrasound provided high-quality images in all cases and demonstrated the location, size, and flow characteristics of the AVM and any associated hematoma. Delayed postoperative cerebral angiography demonstrated successful AVM resection in all cases. An assessment of clinical outcomes revealed no new long-term neurological deficits at 3 months postoperatively. CONCLUSIONS Intraoperative Doppler ultrasonography is a reliable and useful tool for intraoperative localization and guidance for AVM resection in the pediatric population. When used in conjunction with neuronavigation equipment and modern microscopes, this technique has shown a very high complete resection rate with extremely low associated morbidity.

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“…12,13,42 A functional outcome was considered good when the patient could perform the activities of daily living independently (assessed as an mRS score ≤ 2), while the outcome was considered poor when the patient required assistance (mRS Score 3-5) or had died (mRS Score 6). Any causes of death were recorded.…”

Section: Patient Outcomementioning

confidence: 99%

Extent of collateralization predicting symptomatic cerebral vasospasm among pediatric patients: correlations among angiography, transcranial Doppler ultrasonography, and clinical findings

Moftakhar

Cooke

Fullerton

et al. 2015

PED

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OBJECT Although the development and prevalence of cerebral vasospasm (CV) has been extensively investigated in adults, little data exist on the development of CV in children. The authors hypothesized that even though children have highly vasoreactive arteries, because of a robust cerebral collateral blood flow, they rarely develop symptomatic CV. METHODS The authors retrospectively reviewed their university hospital's neurointerventional database for children (that is, patients ≤ 18 years) who were examined or treated for aneurysmal or traumatic subarachnoid hemorrhage (SAH) during the period 1990–2013. Images from digital subtraction angiography (DSA) were analyzed for the extent of CV and collateralization of the cerebral circulation. Results from transcranial Doppler (TCD) ultrasonography were correlated with those from DSA. Cerebral vasospasm on TCD ultrasonography was defined according to criteria developed for adults. Clinical outcomes of CV were assessed with the pediatric modified Rankin Scale (mRS). RESULTS Among 37 children (21 boys and 16 girls ranging in age from 8 months to 18 years) showing symptoms of an aneurysmal SAH (comprising 32 aneurysms and 5 traumatic pseudoaneurysms), 17 (46%) had CV confirmed by DSA; CV was mild in 21% of these children, moderate in 50%, and severe in 29%. Only 3 children exhibited symptomatic CV, all of whom had poor collateralization of cerebral vessels. Among the 14 asymptomatic children, 10 (71%) showed some degree of vessel collateralization. Among 16 children for whom TCD data were available that could be correlated with the DSA findings, 13 (81%) had CV according to TCD criteria. The sensitivity and specificity of TCD ultrasonography for diagnosing CV were 95% and 59%, respectively. The time to CV onset detected by TCD ultrasonography was 5 ± 3 days (range 2–10 days). Twenty-five (68%) of the children had good long-term outcomes (that is, had mRS scores of 0–2). CONCLUSIONS Children have a relatively high incidence of angiographically detectable, moderate-to-severe CV. Children rarely develop symptomatic CV and have good long-term outcomes, perhaps due to robust cerebral collateral blood flow. Criteria developed for detecting CV with TCD ultrasonography in adults overestimate the prevalence of CV in children. Larger studies are needed to define TCD ultrasonography–based CV criteria for children.

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Superior outcomes in children compared with adults after microsurgical resection of brain arteriovenous malformations

Cited by 64 publications

References 12 publications

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

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

Use of intraoperative Doppler ultrasound with neuronavigation to guide arteriovenous malformation resection: a pediatric case series

Extent of collateralization predicting symptomatic cerebral vasospasm among pediatric patients: correlations among angiography, transcranial Doppler ultrasonography, and clinical findings

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