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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Management of pediatric intracranial arteriovenous malformations: experience with multimodality therapy
Tim E Darsaut1, Raphael Guzman, Mary L Marcellus
1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5325, USA.
Insights
Multimodality therapy improves obliteration rates for pediatric arteriovenous malformations (AVMs), reducing hemorrhage risk. Careful consideration of intervention risks is crucial for high-grade AVMs.
Area of Science:
- Neurology
- Vascular Surgery
- Pediatric Neurosurgery
Background:
- Pediatric arteriovenous malformations (AVMs) present complex management challenges.
- Successful treatment often necessitates a combination of embolization, surgery, and radiosurgery.
Purpose of the Study:
- To evaluate the efficacy and outcomes of multimodality treatment for pediatric AVMs.
- To analyze factors influencing treatment success and clinical outcomes in this population.
Main Methods:
- A retrospective analysis of 120 pediatric patients (<18 years) with AVMs treated between 1985 and 2009.
- Patients received combined or single-modality treatments including radiosurgery, surgery, and endovascular techniques.
- Outcomes assessed included AVM obliteration rates, hemorrhage risk, neurological complications, and functional status (modified Rankin Scale).
Main Results:
- Multimodality therapy significantly improved AVM obliteration rates, especially for high-grade lesions (9% to 26%).
- Disabling neurological complications were more frequent in high-grade AVMs (28%) compared to low-grade (5%).
- Poor final outcomes (mRS ≥ 2) were associated with higher baseline mRS, left-sided location, and high AVM grade.
Conclusions:
- Multimodality therapy offers substantial improvements in obliteration rates and may reduce hemorrhage risk for pediatric AVMs.
- The inherent risks of intervention necessitate careful consideration, particularly for high-grade pediatric AVMs with a poor natural history.
Background:
Successful management of pediatric arteriovenous malformations (AVMs) often requires a balanced application of embolization, surgery, and radiosurgery.
Objective:
To describe our experience treating pediatric AVMs.
Methods:
We analyzed 120 pediatric patients (< 18 years of age) with AVMs treated with various combinations of radiosurgery, surgery, and endovascular techniques.
Results:
Between 1985 and 2009, 76 children with low Spetzler-Martin grade (1-3) and 44 with high-grade (4-5) AVMs were treated. Annual risk of hemorrhage from presentation to initial treatment was 4.0%, decreasing to 3.2% after treatment initiation until confirmed obliteration. Results for AVM obliteration were available in 101 patients. Initial single-modality therapy led to AVM obliteration in 51 of 67 low-grade (76%) and 3 of 34 high-grade (9%) AVMs, improving to 58 of 67 (87%) and 9 of 34 (26%), respectively, with further treatment. Mean time to obliteration was 1.8 years for low-grade and 6.4 years for high-grade AVMs. Disabling neurological complications occurred in 4 of 77 low-grade (5%) and 12 of 43 high-grade (28%) AVMs. At the final clinical follow-up (mean, 9.2 years), 48 of 67 patients (72%) with low-grade lesions had a modified Rankin Scale score (mRS) of 0 to 1 compared with 12 of 34 patients (35%) with high-grade AVMs. On multivariate analysis, significant risk factors for poor final clinical outcome (mRS ≥ 2) included baseline mRS ≥ 2 (odds ratio, 9.51; 95% confidence interval, 3.31-27.37; P < .01), left-sided location (odds ratio, 3.03; 95% confidence interval, 1.11-8.33; P = .03), and high AVM grade (odds ratio, 4.35; 95% confidence interval, 1.28-14.28; P = .02).
Conclusion:
Treatment of pediatric AVMs with multimodality therapy can substantially improve obliteration rates and may decrease AVM hemorrhage rates. The poor natural history and risks of intervention must be carefully considered when deciding to treat high-grade pediatric AVMs.
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