Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children.
A retrospective chart review was conducted examining patients age 0–18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage.
Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures.
Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
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Ahn JH, Phi JH, Kang H-S, Wang KC, Cho BK, Lee JY, Kim GB, Kim SK (2010) A ruptured middle cerebral artery aneurysm in a 13-month-old boy with Kawasaki disease. J Neurosurg Pediatr. 6(2):150–153. https://doi.org/10.3171/2010.5.PEDS1012
Ali A, Basaran B, Yornuk M, Altun D, Aydoseli A, Sencer A, Akinci IO (2013) Factors influencing blood loss and postoperative morbidity in children undergoing craniosynostosis surgery: a retrospective study. Pediatr Neurosurg 49(6):339–346. https://doi.org/10.1159/000368781
Anderson RCE, McDowell MM, Kellner CP, Appelboom G, Bruce SS, Kotchetkov IS, Haque R, Feldstein NA, Connolly ES, Solomon RA, Meyers PM, Lavine SD (2012) Arteriovenous malformation-associated aneurysms in the pediatric population. J Neurosurg Pediatr 9(1):11–16. https://doi.org/10.3171/2011.10.PEDS11181
Barone DG, Marcus HJ, Guilfoyle MR, Higgins JNP, Antoun N, Santarius T, Trivedi RA, Kirollos RW (2017) Clinical experience and results of microsurgical resection of Arterioveonous malformation in the presence of space-occupying Intracerebral hematoma. Neurosurgery. 81(1):75–86. https://doi.org/10.1093/neuros/nyx003
Beecher JS, Lyon K, Ban VS et al (2018) Delayed treatment of ruptured brain AVMs: is it ok to wait? J Neurosurg 128(4):999–1005. https://doi.org/10.3171/2017.1.JNS16745
Dorfer C, Czech T, Bavinzski G, Kitz K, Mert A, Knosp E, Gruber A (2010) Multimodality treatment of cerebral AVMs in children: a single-Centre 20 years experience. Childs Nerv Syst 26(5):681–687. https://doi.org/10.1007/s00381-009-1039-8
Freeman WD (2015) Management of intracranial pressure. Contin Minneap Minn 21(5 Neurocritical Care):1299–1323. https://doi.org/10.1212/CON.0000000000000235
Hoh BL, Ogilvy CS, Butler WE, Loeffler JS, Putman CM, Chapman PH (2000) Multimodality treatment of Nongalenic Arteriovenous malformations in pediatric patients. Neurosurgery. 47(2):346–358. https://doi.org/10.1097/00006123-200008000-00015
Kurokawa T, Matsuzaki A, Hasuo K, Fukui M, Tomita S, Matsuo M, Chen YJ, Kasemkosolsri C (1985) Cerebral arteriovenous malformations in children. Brain and Development 7(4):408–413. https://doi.org/10.1016/S0387-7604(85)80138-8
Ma L, Chen X-L, Chen Y, Wu C-X, Ma J, Zhao Y-L (2017) Subsequent haemorrhage in children with untreated brain arteriovenous malformation: higher risk with unbalanced inflow and outflow angioarchitecture. Eur Radiol 27(7):2868–2876. https://doi.org/10.1007/s00330-016-4645-3
Meyer PG, Orliaguet GA, Zerah M, Charron B, Jarreau MM, Brunelle F, Laurent-Vannier A, Carli PA (2000) Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations. Can J Anaesth J Can Anesth 47(8):758–766. https://doi.org/10.1007/BF03019478
Pellettieri L, Svendsen P, Wikholm G, Carlsson CA (1997) Hidden compartments in AVMs--a new concept. Acta Radiol Stockh Swed 1987 38(1):2–7
Ranger A, Szymczak A, Fraser D, Salvadori M, Jardine L (2009) Bilateral decompressive craniectomy for refractory intracranial hypertension in a child with severe ITP-related intracerebral haemorrhage. Pediatr Neurosurg 45(5):390–395. https://doi.org/10.1159/000260910
Shtaya A, Millar J, Sparrow O (2017) Multimodality management and outcomes of brain arterio-venous malformations (AVMs) in children: personal experience and review of the literature, with specific emphasis on age at first AVM bleed. Childs Nerv Syst 33(4):573–581. https://doi.org/10.1007/s00381-017-3383-4
Sorenson TJ, Brinjikji W, Bortolotti C, Kaufmann G, Lanzino G (2018) Recurrent brain Arteriovenous malformations (AVMs): a systematic review. World Neurosurg 116:e856–e866. https://doi.org/10.1016/j.wneu.2018.05.117
Stein K-P, Huetter B-O, Goericke S, Oezkan N, Leyrer R, Sandalcioglu IE, Forsting M, Sure U, Mueller O (2018) Cerebral arterio-venous malformations in the paediatric population: angiographic characteristics, multimodal treatment strategies and outcome. Clin Neurol Neurosurg 164:164–168. https://doi.org/10.1016/j.clineuro.2017.12.006
Tucker EW, Jain SK, Mahesh M (2017) Balancing the risks of radiation and anesthesia in pediatric patients. J Am Coll Radiol 14(11):1459–1461. https://doi.org/10.1016/j.jacr.2017.06.014
Weil AG, Li S, Zhao J-Z (2011) Recurrence of a cerebral arteriovenous malformation following complete surgical resection: a case report and review of the literature. Surg Neurol Int 2. https://doi.org/10.4103/2152-7806.90692
Zhang Q, Peng Y, Wang Y (2017) Long-duration general anesthesia influences the intelligence of school age children. BMC Anesthesiol 17(1):170. https://doi.org/10.1186/s12871-017-0462-8
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LoPresti, M.A., Goethe, E.A. & Lam, S. Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy. Childs Nerv Syst (2020). https://doi.org/10.1007/s00381-020-04501-0
- Pediatric arteriovenous malformation
- Arteriovenous malformation rupture
- Decompressive craniectomy
- Arteriovenous malformation resection