Microsurgical Treatment of Pediatric Arteriovenous Malformations: A Large Single Center Case Series

Introduction: Arteriovenous malformations (AVMs) in the pediatric population carry a lifetime risk of hemorrhage, seizures, neurological deficits, and headaches. Given the long life-expectancy of children, a surgical cure is preferred if it can be accomplished with low morbidity. The scarcity, variety in presentation, and variety of anatomical factors for AVMs can make decision making more difficult. Optimal patient counseling and treatment strategies require full understanding of surgical options and outcomes. Unfortunately, there are few large series detailing the microsurgical outcomes of pediatric AVMs.

Methods: All pediatric patients who had angiographically confirmed diagnosis of cerebral AVM over a 15-year period at a single institution were retrospectively reviewed. Demographics, clinical data, and anatomical features were analyzed. Outcomes for patients undergoing microsurgical treatment were also analyzed.

Results: 61 patients with cerebral AVM were identified. 41 underwent microsurgical treatment. Spetzler-Martin grade was I, II, or III for 40 of 41 patients. 19 underwent adjunctive pre-operative embolization. Complete obliteration rate was 95%. One patient with a small deep residual was treated with radiosurgery, and later achieved complete obliteration. Another patient with small deep residual is being managed with close observation. 3 patients had delayed recurrences that were treated with repeat surgery. Post-operative deficits occurred in 6 patients, 2 with hemianopsia and 4 with motor deficits. All were patients with AVMs in eloquent cortex. 4 of these 6 patients had significant improvement at last follow up. 4 patients had new onset of seizures post-operatively. mRS score at last follow up was 0-2 for 38 patients, a 3 for two patients, and 4 for one patient. Average follow up was 2.8 years.

Conclusion : Microsurgical resection of pediatric AVMs has high rates of obliteration with good outcomes in select patients. Continued long term follow is recommended due to potential for recurrence. Location in eloquent cortex is a strong predictor for post-operative deficit.