Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study.

Lukasz Antkowiak,Monika Putz,Marta Rogalska,Marek Mandera

doi:10.3390/children8030215

Abstract

Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.

Highlights

Brain arteriovenous malformations are intracranial vascular lesions characterized by abnormal connections between the arterial and venous systems without an interposed capillary bed.Pediatric bAVMs constitute merely 12–18% of all diagnosed bAVMs [1]
Multiple factors, such as diffuse and small nidus, deep and infratentorial location, deep venous drainage, single draining vein, single feeding artery, and high Spetzler-Martin grade were identified as positive predictors for the hemorrhagic presentation of bAVM in children [6,7]
The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodal approach in the management of pediatric ruptured bAVMs

Summary

Introduction

Brain arteriovenous malformations (bAVMs) are intracranial vascular lesions characterized by abnormal connections between the arterial and venous systems without an interposed capillary bed.Pediatric bAVMs constitute merely 12–18% of all diagnosed bAVMs [1]. Initial presentation with bAVM rupture occurs more frequently in the pediatric population than in the adult population and accounts for 58–77% of admissions [2]. Ruptured bAVMs account for 30–50% of intracranial bleeding in the pediatric population and are the most common cause of childhood hemorrhagic stroke [1]. Multiple factors, such as diffuse and small nidus, deep and infratentorial location, deep venous drainage, single draining vein, single feeding artery, and high Spetzler-Martin grade were identified as positive predictors for the hemorrhagic presentation of bAVM in children [6,7]. A prior history of ruptured bAVM remains the strongest independent predictor of re-hemorrhage [8]

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