Pediatric Brain AVM: The Role of DSA During Surgery in Hybrid Operating Room

Brain arteriovenous malformations (BAVM) are congenital vascular malformations in which abnormal communication is formed between arteries and veins. Pediatric BAVM was more prone to hemorrhage than adult BAVM. And the natural course of pediatric BAVM was more severe than that of adult BAVM.Among the three main treatment options, surgical resection offers the highest cure rate. Surgical resection was prioritized when the total score of the supplementary Spetzler-Martin grade was ≤6. This approach was especially emphasized for children with ruptured AVMs and for younger patients who were not suitable candidates for stereotactic radiotherapy. However, for unruptured BAVMs located near functional areas, stereotactic radiotherapy could be considered the preferred treatment option.A hybrid operating room allows the simultaneous performance of open surgery and interventional procedures. The primary benefit of a hybrid operating room is the ability to determine residual BAVM through intraoperative DSA, ensuring complete resection. Furthermore, for BAVMs with higher Spetzler-Martin grades, those located in eloquent areas, with complex structures or diffuse types, or those that have previously undergone surgery, these cases are particularly well-suited for procedures performed in a hybrid operating room. For patients with large hematomas requiring emergency decompression, emergency surgery in a hybrid operating room is a more reasonable option. In such a setting, preoperative DSA, surgical resection, and postoperative DSA can be performed within the same session.From 2015 to 2024, a total of 123 cases of surgical resection of BAVM in children were performed at this center using a hybrid operating room. Residual BAVM was identified during the first intraoperative DSA in 10 cases (8%). There were 8 cases (6.5%) of confirmed recurrence by DSA.BAVM remains the most challenging disease for neurosurgeons. Individualized treatment strategy needs to be formulated for each pediatric patient.