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Arteriovenous malformations of the brain in children: a forty year experience
D Kondziolka1, R P Humphreys, H J Hoffman
1Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada.
Insights
Pediatric brain arteriovenous malformations (AVMs) carry high risks. Surgical treatment significantly reduces mortality and seizure risk, with complete AVM resection leading to favorable neurological outcomes.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Vascular Neurology
Background:
- Pediatric brain arteriovenous malformations (AVMs) are associated with significant morbidity and mortality.
- Hemorrhage is a common presentation in childhood AVMs, with historically high mortality rates.
Purpose of the Study:
- To examine clinical data and management outcomes for 132 pediatric brain AVM patients treated between 1949 and 1989.
- To evaluate the impact of diagnostic and therapeutic advancements on AVM-related outcomes.
Main Methods:
- Retrospective review of clinical data from 132 pediatric patients with brain AVMs.
- Analysis of hemorrhage rates, mortality, seizure disorders, and treatment outcomes (surgical vs. non-operative).
Main Results:
- Hemorrhage occurred in 79% of pediatric AVM cases.
- Mortality from AVM hemorrhage decreased from 39% to 16% after the introduction of computed tomography.
- Cerebellar AVMs had a significantly higher mortality rate (57%) compared to cerebral hemisphere AVMs (4.5%).
- Surgical excision achieved complete seizure control in 73% of patients.
- Complete AVM resection resulted in a normal neurological outcome in 67% of cases.
Conclusions:
- Surgical treatment of pediatric brain AVMs is associated with reduced mortality and improved neurological outcomes.
- Complete AVM resection is crucial for preventing rehemorrhage and achieving seizure control.
- All children with AVMs should be considered for treatment to mitigate hemorrhage risk.
Abstract:
Despite the great capacity for the pediatric brain to recover from stroke, the morbidity and mortality in children who harbor an arteriovenous malformation (AVM) remains high. This study examines the clinical data and management experience with 132 patients with brain AVM from 1949 to 1989. Although the high tendency for a childhood AVM to present with hemorrhage (79%) remained constant for the forty year study period, the associated morbidity and mortality of hemorrhage changed. The mortality rate from hemorrhage for the entire series was 25%, which was reduced from 39% to 16% after the introduction of computed tomography. The mortality from AVM hemorrhage since 1975 was dependent on location; 8 of 14 patients (57%) with a cerebellar AVM died from hemorrhage while only 2 of 44 patients (4.5%) with a cerebral hemisphere AVM died (p less than 0.0001). Sixteen children (12%) presented with a chronic seizure disorder. Surgical excision of the malformation resulted in complete seizure control off anti-convulsant medication in 73% of patients. Although 21% of patients were treated non-operatively (many with terminal poor-grade hemorrhage), 79% had a surgical procedure with total AVM excision achieved in 70 patients (53.1%). Complete AVM resection was followed by a normal neurological outcome in 47 children (67%). Most partial excisions (n = 9) and clipping of feeding arteries (n = 7) were performed in the early years of this study, and did not provide protection from rehemorrhage. Although conservative management has been advocated for selected non-hemorrhagic AVMs, we conclude that essentially all children with an AVM should be treated in order to eliminate the risk of hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)