Management of Pediatric Intracranial Arteriovenous Malformations

Abstract

Pediatric intracranial arteriovenous malformations (AVMs) are challenging lesions managed by pediatric neurosurgeons. The high risk of hemorrhage and neurologic injury is compounded by the unique anatomy of each malformation that requires individualizing treatment options. This article reviews the current status of pediatric AVM epidemiology, pathophysiology and clinical care, with a specific focus on the rationale and methodology of surgical resection.

Keywords: Arteriovenous malformations; Pediatrics; Perioperative care; Stroke.

Fig. 1.

Use of an intraoperative ultrasound to help localize clot (red arrowhead on CT) and AVM nidus (blue arrowhead on CTA) in order to guide controlled decompression of the clot through a small dural opening in advance of a wider exposure. Using the Doppler flow settings can be particularly helpful to visualize AVM, especially when paired with CT/CTA studies. CT : computed tomography, AVM : arteriovenous malformation, CTA : computed tomography angiography.

Fig. 2.

Angiographic correlation with intraoperative photograph highlighting conical shape of arteriovenous malformation, including both surface findings and surgical technique of working around the “cone” of the nidus, walling the margins off with cottonoids.

Fig. 3.

Intraoperative microscope images demonstrating small tuft of arterial vessels near ependyma of ventricle at base of arteriovenous malformation (left image, blue arrowhead) with subsequent cauterization and division of these feeders (right image). In addition, this image also highlights the utility of having an assistant working under the microscope to improve visualization and minimize prolonged retraction on adjacent brain.