Endovascular treatment of pial AVMs: technical options, indications and limits in pediatric age patients

Our study group consisted of 29 patients who underwent endovascular treatment for the presence of pial AVMs. The patients were treated with various embolization methods including "-free flow" embolization (2 cases); embolization with suture threads (2 mm long micro-emboli: 17 cases) and embolization with acrylic glue (10 cases). There were significant angio-architectural and AVM location differences between the pediatric and the adult patient groups. In pediatric patients, the more frequent AVMs were of the mono or few-pedunculated type, then simple direct fistulas and high-flow fistulous-plexiform AVMs and giant infra-tentorial or deep-seated malformations. In mono or few-pedunculated AVMs, the elected treatment was acrylic glue followed by radio-surgery achieving definitive cure in 3 cases. In direct AVFs and elevated flow AVMs, embolization with suture and acrylic glue offered definitive results. Treatment for infra-tentorial and deep-seated AVMs presented the greatest difficulty in pediatric patients. In two of them, embolization with glue enabled radiosurgery (giant cerebellar AVMs). Our experience did not confirm that current endovascular techniques provide definitive treatment in extensive, deep-seated AVMs. Each treatment, in children more so than in adults, requires a risk/benefit evaluation of the method taking into account the natural history data.