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Canadian Journal of Anaesthesia

, Volume 41, Issue 4, pp 321–331 | Cite as

Cerebral arteriovenous malformations in children

  • Carol Millar
  • Bruno Bissonnette
  • R. P. Humphreys
Review Articles

Abstract

The treatment of cerebral arteriovenous malformations (AVM) or vascular anomalies are challenging neurosurgical procedures for an anaesthetist. Large AVMs are uncommon in children. Only 18% of AVMs become symptomatic before the age of 15 yr. This series reviews the experience at this institution during the period of 1982 to 1992. The symptoms at the time of presentation are varied and include haemorrhage (50%), seizures and hydrocephalus (36%) or congestive cardiac failure (18%). Symptoms of congestive heart failure predominate in the new-born whilst neurological symptoms, such as stroke, seizures or hydrocephalus occur more commonly in infants and older children. Approximately one third of AVMs in childhood present acutely. Radiological investigations, e.g., CT scan, MRI and cerebral angiography are essential to identify the precise location of the lesion. Therapeutic intervention in the acute presentation may involve craniotomy for evacuation of haematoma and treatment of increased intracranial pressure (ICP). Control of seizures and congestive heart failure may take priority and allow time to plan the elective procedures of embolization and surgical excision of the AVM. Operative intervention is hazardous and peroperative complications can be expected in more than 50% of patients. The morbidity and mortality associated with cerebral AVM are high, especially in infants who present in the neonatal period with congestive cardiac failure. The overall mortality in this series was 20%. Children presenting with intracranial arteriovenous malformations require a multidisciplinary approach. The successful management of anaesthesia either for embolization or surgical resection necessitates an understanding of the disciplines of paediatric and neuroanaesthesia. Special care and specific attention to detail may contribute to reduce the high morbidity and mortality encountered in these compromised children.

Key words

anaesthesia: paediatric, neuroanaesthesia surgery: paediatric, neurological arteriovenous malformation 

Résumé

Le traitement neurochirurgical des malformations cérébrales artérioveineuses (MAV) représente pour l’anesthésie un défi majeur. Les grosses MAV sont rares chez l’enfant. Seulement 18% deviennent symptomatiques avant l’âge de 15 ans. D’après notre expérience de 1982 à 1992, les premières manifestations sont variables: hémorragie (50%), convulsions et hydrocéphalie Q6%) ou défaillance cardiaque globale (18%). Les symptômes de la défaillance cardiaque globale prédominent chez le nouveau-né alors que les symptômes neurologiques, comme les convulsions et l’hydrocéphalie surviennent plus fréquemment chez le nourrison et l’enfant plus âgé. Environ un tiers des MAV de l’enfance se manifest subitement. Les études radiologiques comme la tomodensitométrie, l’imagerie par résonance magnétique et l’angiographie cérébrale sont essentielles pour l’identification précise du site de la lésion. Le traitement peut signifier une craniotomie pour l’évacuation d’un hématome et le traitement de l’hypertension intracrânienne. Le contrôle des convulsions et de la défaillance cardiaque est souvent prioritaire et permet de planifier des interventions programmées d’embolisation et d’excision chirurgicale de la MAV. L’intervention chirurgicale est dangereuse et on peut s’attendre à des complications peropératoires dans 50% des cas. La morbidité et la mortalité associées aux MAV sont élevées, spécialement en cas de défaillance cardiaque à la période néonatale. Dans notre série, la mortalité totale est de 20%. Ces cas doivent être traités par une équipe multidisciplinaire. Une conduite anesthésique efficace pour embolisation ou résection chirurgicale nécessite une bonne compréhension de l’anesthésie pèdiatrique et neurochirurgicale. Des soins spéciaux et une attention particuliere aux détails peuvent contribuer à diminuer la morbidité et la mortalité élevées de ces enfants très malades.

References

  1. 1.
    Padget DH. The cranial venous system in man in reference to development, adult configuration and relation to the arteries. American Journal of Anatomy 1956; 98: 307–40.PubMedCrossRefGoogle Scholar
  2. 2.
    Swash M, Oxbury J. Haemorrhagic disorders.In: Swash M, Oxbury J (Eds.). Clinical Neurology, 1st Ed. New York: Churchill Livingstone, 1991; 1016.Google Scholar
  3. 3.
    Michelsen WJ. Natural history and pathophysiology of arteriovenous malformations. Clin Neurosurg 1979; 26: 307–13.PubMedGoogle Scholar
  4. 4.
    Graf CJ, Perret GE, Tomer JC. Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 1983; 58: 331–7.PubMedGoogle Scholar
  5. 5.
    Ford FR. Vascular lesions and circulatory disorders: arteriovenous malformations.In: Diseases of the Nervous System in Infancy, Childhood and Adolescence; 6th ed. Springfield, Illinois: CC Thomas. 1034–41.Google Scholar
  6. 6.
    Kondziolka D, Humphreys RP, Hoffman HJ, Hendrick ER, Drake JM. Arteriovenous malformations of the brain in children: a forty year experience. Can J Neurol Sci 1992; 19: 40–5.PubMedGoogle Scholar
  7. 7.
    Mendelow AD, Erfurth A, Grossart K, Macpherson P. Do cerebral arteriovenous malformations increase in size? J Neurol Neurosurg Psychiatry 1987; 50: 980–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Minakawa T, Tanaka R, Koike T, Takeuchi S, Sasaki O. Angiographic follow-up study of cerebral arteriovenous malformations with reference to their enlargement and regression. Neurosurgery 1989; 24: 68–74.PubMedCrossRefGoogle Scholar
  9. 9.
    Wakabayashi S, Ohno K, Shishida T, Tamaki M, Matsushima Y, Hirakawa K. Marked growth of a cerebral arteriovenous malformation: case report and review of the literature. Neurosurgy 1991; 29: 920–3.CrossRefGoogle Scholar
  10. 10.
    Norman MG, Becker LE. Cerebral damage in neonates resulting from arteriovenous malformation of the vein of Galen. J Neurol Neurosurg Psychiatry 1974; 37: 252–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Gomez MR, Whitten CF, Noike A, Bernstein J, Meyer JS. Aneurysmal malformation of the Galen causing heart failure in early infancy. Report of five cases. Pediatrics 1963; 31: 400–11.Google Scholar
  12. 12.
    Knudson RP, Alden ER. Symptomatic arteriovenous malformation in infants less than 6 months of age. Pediatrics 1979; 64: 238–41.PubMedGoogle Scholar
  13. 13.
    Pasqualin A, Barone G, Cioffe F, Rosta L, Scienza R, Da Pian R. The relevance of anatomic and hemodynamic factors to a classification of cerebral arteriovenous malformations. Neurosurgery 1991; 28: 370–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Schoenberg B, Mellinger J, Schoenberg D. Cerebrovascular disease in infants and children: a study of incidence, clinical features and survival. Neurology 1978; 28: 763–8.PubMedGoogle Scholar
  15. 15.
    Humphreys RP. Arteriovenous malformations of the brain.In: McLaurin RL, Schut L, Venes JL, Epsein F (Eds.). Pediatric Neurosurgery: Surgery of the Developing Nervous System. 2nd Ed. Philadelphia: WB Saunders Company. 1989; 508–16.Google Scholar
  16. 16.
    Melville C, Walsh K, Sreeram N. Cerebral arteriovenous malformations in the neonate: clinical presentation, diagnosis and outcome. Int J Cardiol 1991; 31: 175–80.PubMedCrossRefGoogle Scholar
  17. 17.
    McLeod ME, Creighton RE, Humphreys RP. Anaesthesia for cerebral ateriovenous malformations in children. Can Anaesth Soc J 1982; 29: 299–305.PubMedCrossRefGoogle Scholar
  18. 18.
    Ravussin P, Guinard JP, Ralley F, Thorin D. Effect of propofol on cerebrospinal fluid pressure and cerebral perfusion pressure in patients undergoing craniotomy. Anaesthesia 1988 Suppl.; 43: 37–41.PubMedCrossRefGoogle Scholar
  19. 19.
    Adams RW, Cuiciara RF, Gronnert GA. Isoflurane and cerebrospinal fluid pressure in neurosurgical patients. Anesthesiology 1981; 54: 97–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Fitch W, Barker J, Jenneu WB, McDowall DG. The influence of neurolept analgesic drugs on cerebrospinal fluid pressure. Br J Anaesth 1969; 41: 800–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Hung OR, Hope CE, Laney G, Whynot SC, Coonan TJ, Malloy DS. The effect of alfentanil on intracranial dynamics and hemodynamics in patients with brain tumour undergoing craniotomy. Can J Anaesth 1992; 39: A4.Google Scholar
  22. 22.
    Graves VB, Duff TA. Intracranial arteriovenous malformations; current imaging and treatment. Invest Radiol. 1990; 25: 952–60.PubMedCrossRefGoogle Scholar
  23. 23.
    Higashida RT, Hieshima GB, Halbach VV. Advances in the treatment of complex cerebrovascular disorders by interventional neurovascular techniques. Circulation 1991; 83: Suppl 1: 196–206.Google Scholar
  24. 24.
    Hannedouche A, Mann C, Lasjaunias P, Dubousset AM. Prise en charge anesthésique pour bilan artériographique et traitement endovascularie des enfants porteurs d’une malformation artérioveineuse de la veine de Galien. Agressologie 1990; 31: 287–9.PubMedGoogle Scholar
  25. 25.
    Yantada S, Brauer FS, Knierim DS. Direct approach to arteriovenous malformations in functional areas of the cerebral hemisphere. J Neurosurg 1990; 72: 418–25.Google Scholar
  26. 26.
    Newman B, Gelb AW, Lam AM. The effect of isofluraneinduced hypotension on cerebral blood flow and cerebral metabolic rate for oxygen in humans. Anesthesiology 1986; 64: 307–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Strandgaard S, Paulson OB. Cerebral autoregulation. Stroke 1984; 15: 413–6.PubMedGoogle Scholar
  28. 28.
    Krane EJ, Domino KB. Anaesthesia for neurosurgery.In: Motoyama EK, Davis PJ (Eds.). Smith’s Anesthesia for Infants and Children. 5th ed. St. Louis: CV Mosby and Co. 1990.Google Scholar
  29. 29.
    Swedlow DB. Anaesthesia for neurosurgical procedures Vol. 1.In: Gregory GA (Ed.). Pediatric Anesthesia. 2nd ed. New York: Churchill Livingstone, 1989; 961–91.Google Scholar
  30. 30.
    Hartley EJ, Bissonnette B, St-Louis P, Rybczynski J, McLeod ME. Scalp infiltration with bupivacaine in pediatric brain surgery. Anesth Analg 1991; 73: 29–32.PubMedCrossRefGoogle Scholar
  31. 31.
    Henriksen L, Thorshauge C, Harmsen A, et al. Controlled hypotension with sodium nitroprusside: effects on cerebral blood flow and cerebral venous blood gases in patients operated for cerebral aneurysms. Acta Anaesthesiol Scand 1983; 27: 62–7.PubMedGoogle Scholar
  32. 32.
    Hewitt PE, Machin SJ. Massive blood transfusion.In: BMJ ABC of Blood Transfusion. Rugby: Jolly and Barber Ltd. 1990; 38–40.Google Scholar
  33. 33.
    Donaldson MDJ, Seaman MJ, Park GR. Massive blood transfusion. Br J Anaesth 1992; 69: 621–30.PubMedCrossRefGoogle Scholar
  34. 34.
    Linko K, Saxelin I. Electrolyte and acid base disturbances caused by blood transfusions. Acta Anaesthesiol Scand 1986; 30: 139–44.PubMedGoogle Scholar
  35. 35.
    Brown KA, Bissonnette B, McIntyre B. Hyperkalaemia during rapid blood transfusion and hypovolaemic cardiac arrest in children. Can J Anaesth 1990; 37: 747–54.PubMedGoogle Scholar
  36. 36.
    Messick JM Jr, Milde LM. Brain protection. Advances in Anesthesiology 1987; 4: 47–88.Google Scholar
  37. 37.
    Hall R, Murdoch J. Brain protection: physiology and pharmacological considerations. Part II: The pharmacology of brain protection. Can J Anaesth 1990; 37: 762–77.PubMedGoogle Scholar
  38. 38.
    Hamill JF, Bedford RF, Weaver DC, Colohan AR. Lidocaine before endotracheal intubation: intravenous or laryngotracheal? Anesthesiology 1981; 55: 578–81.PubMedCrossRefGoogle Scholar
  39. 39.
    Unni VKN, Johnston RA, Young HSA, McBride RJ. Prevention of intracranial hypertension during laryngoscopy and endotracheal intubation. Use of a second dose of thiopentone. Br J Anaesth 1984; 56: 1219–23.PubMedCrossRefGoogle Scholar
  40. 40.
    Cucchiara RF, Benefiel DJ, Matteo RS, De Wood M, Albin MS. Evaluation of esmolol in controlling increases in heart rate and blood pressure during endotracheal intubation in patients undergoing carotid endarterectomy. Anesthesiology 1986; 65: 528–31.PubMedCrossRefGoogle Scholar
  41. 41.
    Garner L, Stirt JA, Finholt DA. Heart block after intravenous lidocaine in an infant. Can Anaesth Soc J 1985; 32: 425–8.PubMedGoogle Scholar
  42. 42.
    Splinter WM. Intravenous lidocaine does not attenuate the haemodynamic response of children to laryngoscopy and tracheal intubation. Can J Anaesth 1990; 37: 440–3.PubMedCrossRefGoogle Scholar
  43. 43.
    Pulsinelli WA, Waldman S, Rawlinson D, Plum F. Moderate hyperglycemia augments ischemic brain damage: a neuropathologic study in the rat. Neurology 1982; 32: 1239–46.PubMedGoogle Scholar
  44. 44.
    Drummond JC. Changing practices in neuroanaesthesia. Can J Anaesth 1990; 37: Slxxxix-Sxcix.PubMedGoogle Scholar
  45. 45.
    Hood JB, Wallace CT, Mahaffey JE. Anesthetic management of an intracranial arteriovenous malformation in infancy. Anesth Analg 1977: 56: 236–41.PubMedCrossRefGoogle Scholar
  46. 46.
    Morley-Forster PK. Unintentional hypothermia in the operating room. Can Anaesth Soc J 1986; 33: 516–28.Google Scholar
  47. 47.
    Minamisawa H, Nordström CH, Smith ML, Siesjo BK. The influence of mild body and brain hypothermia on ischemic brain damage. J Cereb Blood Flow Metab 1990; 10: 365–74.PubMedGoogle Scholar
  48. 48.
    Goudsouzian NG, Morris RH, Ryan JF. The effects of a warming blanket on the maintenance of body temperatures in anesthetized infants and children. Anesthesiology 1973; 39: 351–3.PubMedCrossRefGoogle Scholar
  49. 49.
    Fonkalsrud EW, Calmes S, Barcliff LT, Barrett CT. Reduction of operative heat loss and pulmonary secretions in neonates by use of heated and humidified anesthetic gases. J Thorac Cardiovasc Surg 1980; 80: 718–23.PubMedGoogle Scholar
  50. 50.
    Bissonnette B, Sessler DI, LaFlamme P. Passive and active inspired gas humidification in infants and children. Anesthesiology 1989; 71: 350–4.PubMedCrossRefGoogle Scholar
  51. 51.
    Bennett EJ, Patel KP, Grundy EM. Neonatal temperature and surgery. Anesthesiology 1977; 46: 303–4.PubMedCrossRefGoogle Scholar
  52. 52.
    DeFalque RJ, Musunru VS. Diseases of the nervous system.In: Stoelting RK. Anaesthesia and Co-Existing Diseases. 2nd Ed. New York: Churchill Livingstone 1988; 272–4.Google Scholar
  53. 53.
    Marshall LF, Smith RW, Rauscher LA, Shapiro HM. Mannitol dose requirements in brain-injured patients. J Neurosurg 1978; 48: 169–72.PubMedGoogle Scholar
  54. 54.
    Cottrell JE, Robustelli A, Post K, Turndorf H. Furosemide- and mannitol-induced changes in intracranial pressure and serum osmolality and electrolytes. Anesthesiology 1977; 47: 28–30.PubMedCrossRefGoogle Scholar
  55. 55.
    Dorman HR, Sondheimer JH, Cadnapaphornchai P. Mannitol-induced acute renal failure. Medicine 1990; 69: 153–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Guidetti B, Delitala A. Intracranial arteriovenous malformations. Conservative and surgical treatment. J Neurosurg 1980; 53: 149–52.PubMedGoogle Scholar
  57. 57.
    Malik GM, Sadasivan B, Knighton RS, Ausman JI. The management of arteriovenous malformation in children. Childs Nerv Syst 1991; 7: 43–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Garcia-Monaco R, De Victor D, Mann C, Hannedouche A, Terbrugge K, Lasjaunias P. Congestive cardiac manifestations from cerebrocranial arteriovenous shunts. Childs Nerv Syst 1991; 7: 48–52.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1994

Authors and Affiliations

  • Carol Millar
    • 1
  • Bruno Bissonnette
    • 1
  • R. P. Humphreys
    • 2
  1. 1.Departments of Anaesthesia, The Hospital for Sick ChildrenUniversity of TorontoToronto
  2. 2.Departments of Surgery, The Hospital for Sick ChildrenUniversity of TorontoToronto

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