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Cerebral arteriovenous malformations in children
C Millar1, B Bissonnette, R P Humphreys
1Department of Anaesthesia, Hospital for Sick Children, University of Toronto, Ontario, Canada.
Insights
Treating pediatric cerebral arteriovenous malformations (AVM) is complex, with high risks. Early recognition and a multidisciplinary approach are crucial for managing these challenging neurosurgical cases and improving outcomes.
Area of Science:
- Neurosurgery
- Pediatric Anesthesiology
- Vascular Neurology
Background:
- Cerebral arteriovenous malformations (AVM) present unique challenges in pediatric neurosurgery.
- Large AVMs are rare in children, with only 18% symptomatic before age 15.
- Presentation varies, including hemorrhage (50%), seizures/hydrocephalus (36%), and congestive heart failure (18%).
Purpose of the Study:
- To review institutional experience with pediatric cerebral AVM from 1982-1992.
- To analyze presentation, management, and outcomes of these cases.
- To highlight the importance of a multidisciplinary approach and specialized anesthesia.
Main Methods:
- Retrospective review of pediatric cerebral AVM cases treated between 1982 and 1992.
- Analysis of clinical presentation, radiological findings (CT, MRI, angiography), and therapeutic interventions.
- Evaluation of operative complications, morbidity, and mortality rates.
Main Results:
- Congestive heart failure predominated in newborns; neurological symptoms in older children.
- Approximately one-third of pediatric AVMs presented acutely.
- Operative intervention carried significant risks, with over 50% experiencing peroperative complications.
- Overall mortality in the series was 20%, particularly high in neonates with cardiac failure.
Conclusions:
- Pediatric cerebral AVM management demands a multidisciplinary strategy.
- Anesthesia for embolization or surgical resection requires expertise in pediatric and neuroanesthesia.
- Attention to detail in anesthetic management is vital to reduce high morbidity and mortality.
Abstract:
The treatment of cerebral arteriovenous malformations (AVM) or vascular anomalies are challenging neurosurgical procedures for an anaesthetist. Large AVMs are uncommon in children. Only 18% of AVMs become symptomatic before the age of 15 yr. This series reviews the experience at this institution during the period of 1982 to 1992. The symptoms at the time of presentation are varied and include haemorrhage (50%), seizures and hydrocephalus (36%) or congestive cardiac failure (18%). Symptoms of congestive heart failure predominate in the newborn whilst neurological symptoms, such as stroke, seizures or hydrocephalus occur more commonly in infants and older children. Approximately one third of AVMs in childhood present acutely. Radiological investigations, e.g., CT scan, MRI and cerebral angiography are essential to identify the precise location of the lesion. Therapeutic intervention in the acute presentation may involve craniotomy for evacuation of haematoma and treatment of increased intracranial pressure (ICP). Control of seizures and congestive heart failure may take priority and allow time to plan the elective procedures of embolization and surgical excision of the AVM. Operative intervention is hazardous and peroperative complications can be expected in more than 50% of patients. The morbidity and mortality associated with cerebral AVM are high, especially in infants who present in the neonatal period with congestive cardiac failure. The overall mortality in this series was 20%. Children presenting with intracranial arteriovenous malformations require a multidisciplinary approach. The successful management of anaesthesia either for embolization or surgical resection necessitates an understanding of the disciplines of paediatric and neuroanaesthesia. Special care and specific attention to detail may contribute to reduce the high morbidity and mortality encountered in these compromised children.