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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Acute surgical management of children with ruptured brain arteriovenous malformation
Sarah Stricker1, Grégoire Boulouis2,3, Sandro Benichi1,2
11APHP, Necker Hospital.
Insights
Emergency hemorrhage evacuation (HE) is crucial for children with ruptured brain arteriovenous malformations (AVMs) causing intracerebral hemorrhage (ICH). Factors like low GCS, high ICH/brain volume ratio, and herniation predict the need for HE, which offers good outcomes.
Area of Science:
- Pediatric Neurosurgery
- Neurology
- Vascular Malformations
Background:
- Ruptured brain arteriovenous malformations (AVMs) are a primary cause of pediatric intracerebral hemorrhage (ICH).
- Intracranial hypertension following AVM rupture is a critical, modifiable prognostic factor.
- Emergency hemorrhage evacuation (HE) may be necessary to manage elevated intracranial pressure.
Purpose of the Study:
- To identify variables associated with the need for emergency hemorrhage evacuation (HE) in pediatric patients with ruptured AVMs.
- To analyze the association between HE and other acute surgical interventions.
- To evaluate clinical outcomes following management of ruptured AVMs in children.
Main Methods:
- Single-center retrospective analysis of pediatric patients treated for ruptured AVM.
- Evaluation of HE occurrence, timing, and association with procedures like nidal excision and decompressive hemicraniectomy.
- Univariable and multivariable analyses of associated variables; 18-month clinical outcome assessment using the King's Outcome Scale for Childhood Head Injury.
Main Results:
- Hemorrhage evacuation (HE) was performed in 45.5% of 112 ruptured AVM episodes across 104 children.
- Predictors for HE included lower Glasgow Coma Scale score, higher ICH/brain volume ratio, superficial AVM location, and brain herniation.
- Overall mortality was <4%, with 58% favorable outcomes and 87% independent function at 18 months, irrespective of surgical intervention.
Conclusions:
- Emergency hemorrhage evacuation (HE) is a vital, life-saving procedure for nearly half of pediatric patients experiencing AVM rupture.
- Intensive initial management, including HE when indicated, is justified by the favorable overall outcomes observed in this cohort.
- The study underscores the importance of timely intervention in managing the complications of pediatric ruptured AVMs.
Objective:
Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM.
Methods:
This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury.
Results:
A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently.
Conclusions:
HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.
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