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Huguenard AL, Guerriero RM, Tomko SR, Limbrick DD, Zipfel GJ, Guilliams KP, Strahle JM. Immediate Postoperative Electroencephalography Monitoring in Pediatric Moyamoya Disease and Syndrome. Pediatr Neurol 2021; 118:40-45. [PMID: 33773289 DOI: 10.1016/j.pediatrneurol.2021.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Moyamoya disease and syndrome are progressive steno-occlusive cerebrovascular diseases that manifest clinically with ischemic episodes. There is evidence for the use of electroencephalography (EEG) in preoperative and long-term postoperative evaluation of these patients, as well as in the intraoperative period to monitor for changes correlated with perioperative ischemic events. However, the utility of EEG in the immediate postprocedure time period has not previously been described. METHODS We review six patients who underwent pial synangiosis from 2017 to 2019. EEGs from the preoperative, intraoperative, and immediate postoperative period were evaluated, as well as clinical examination changes and subsequent interventions. RESULTS Six patients with postoperative EEG monitoring following pial synangiosis were included. EEG data was collected preoperatively, intraoperatively, and continuously postoperatively. Preoperatively, five of six patients had normal background activity on EEG, whereas one of six had hemispheric asymmetry. Three patients had new or worsening hemispheric intracerebral asymmetry on EEG during the immediate postsurgical period. Two of these had no clinical manifestations of ischemia, and one had transient left facial weakness. All three underwent blood pressure augmentation with improvement in the asymmetry on EEG and clinical improvement in the symptomatic patient. CONCLUSIONS Although widely accepted as a useful tool during the preoperative and intraoperative periods of evaluation and management of moyamoya disease and syndrome, we propose that the use of continuous EEG in the immediate postoperative period may have potential as a useful adjunct by both detecting early clinical and subclinical intracranial ischemia.
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Affiliation(s)
- Anna L Huguenard
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri.
| | - Rejean M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, St. Louis Children's Hospital, St. Louis, Missouri
| | - Stuart R Tomko
- Division of Pediatric and Developmental Neurology, Department of Neurology, St. Louis Children's Hospital, St. Louis, Missouri
| | - David D Limbrick
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Kristin P Guilliams
- Division of Pediatric and Developmental Neurology, Department of Neurology, St. Louis Children's Hospital, St. Louis, Missouri
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
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2
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Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study. CHILDREN-BASEL 2021; 8:children8030215. [PMID: 33799749 PMCID: PMC7998913 DOI: 10.3390/children8030215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
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.
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3
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Meling TR, Patet G. What is the best therapeutic approach to a pediatric patient with a deep-seated brain AVM? Neurosurg Rev 2019; 42:409-416. [PMID: 30980204 DOI: 10.1007/s10143-019-01101-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/27/2019] [Indexed: 11/25/2022]
Abstract
Although brain arteriovenous malformations (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous intracranial hemorrhages. Pediatric bAVMs tend to rupture more frequently and seem to have higher recurrence rates than bAVMs in adults. Thus, the management of pediatric bAVMs is particularly challenging. In general, the treatment options are conservative treatment, microsurgery, endovascular therapy (EVT), gamma knife radiosurgery (GKRS), proton-beam stereotactic radiosurgery (PSRS), or a combination of the above. In order to identify the best approach to deep-seated pediatric bAVMs, we performed a systematic review, according to the PRISMA guidelines. None of the options seem to offer a clear advantage over the others when used alone. Microsurgery provides the highest obliteration rate, but has higher incidence of neurological complications. EVT may play a role when used as adjuvant therapy, but as a stand-alone therapy, the efficacy is low and the long-term side effects of radiation from the multiple sessions required in deep-seated pediatric bAVMs are still unknown. GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population.
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Affiliation(s)
- Torstein R Meling
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
| | - Gildas Patet
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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4
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Ravindra VM, Bollo RJ, Eli IM, Griauzde J, Lanpher A, Klein J, Zhu H, Brockmeyer DL, Kestle JRW, Couldwell WT, Scott RM, Smith E. A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 30952115 DOI: 10.3171/2019.2.peds18731] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits. METHODS The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living. RESULTS Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up. CONCLUSIONS Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.
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Affiliation(s)
- Vijay M Ravindra
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Robert J Bollo
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ilyas M Eli
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Julius Griauzde
- 2Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Arianna Lanpher
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Jennifer Klein
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Huirong Zhu
- 4Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Douglas L Brockmeyer
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - John R W Kestle
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - R Michael Scott
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Edward Smith
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
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Patibandla MR, Ding D, Xu Z, Sheehan JP. Stereotactic Radiosurgery for Pediatric High-Grade Brain Arteriovenous Malformations: Our Experience and Review of Literature. World Neurosurg 2017; 102:613-622. [DOI: 10.1016/j.wneu.2017.03.064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/23/2023]
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Blauwblomme T, Naggara O, Brunelle F, Grévent D, Puget S, Di Rocco F, Beccaria K, Paternoster G, Bourgeois M, Kossorotoff M, Zerah M, Sainte-Rose C, Boddaert N. Arterial spin labeling magnetic resonance imaging: toward noninvasive diagnosis and follow-up of pediatric brain arteriovenous malformations. J Neurosurg Pediatr 2015; 15:451-8. [PMID: 25634818 DOI: 10.3171/2014.9.peds14194] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Arterial spin labeling (ASL)-MRI is becoming a routinely used sequence for ischemic strokes, as it quantifies cerebral blood flow (CBF) without the need for contrast injection. As brain arteriovenous malformations (AVMs) are highflow vascular abnormalities, increased CBF can be identified inside the nidus or draining veins. The authors aimed to analyze the relevance of ASL-MRI in the diagnosis and follow-up of children with brain AVM. METHODS The authors performed a retrospective analysis of 21 patients who had undergone digital subtraction angiography (DSA) and pseudo-continuous ASL-MRI for the diagnosis or follow-up of brain AVM after radiosurgery or embolization. They compared the AVM nidus location between ASL-MRI and 3D contrast-enhanced T1 MRI, as well as the CBF values obtained in the nidus (CBFnidus) and the normal cortex (CBFcortex) before and after treatment. RESULTS The ASL-MRI correctly demonstrated the nidus location in all cases. Nidal perfusion (mean CBFnidus 137.7 ml/100 mg/min) was significantly higher than perfusion in the contralateral normal cortex (mean CBFcortex 58.6 ml/100 mg/min; p < 0.0001, Mann-Whitney test). Among 3 patients followed up after embolization, a reduction in both AVM size and CBF values was noted. Among 5 patients followed up after radiosurgery, a reduction in the nidus size was observed, whereas CBFnidus remained higher than CBFcortex. CONCLUSIONS In this study, ASL-MRI revealed nidus location and patency after treatment thanks to its ability to demonstrate focal increased CBF values. Absolute quantification of CBF values could be relevant in the follow-up of pediatric brain AVM after partial treatment, although this must be confirmed in larger prospective trials.
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Affiliation(s)
- Thomas Blauwblomme
- Assistance Publique Hôpitaux de Paris, Departments of 1 Pediatric Neurosurgery
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Renieri L, Limbucci N, Consoli A, Rosi A, Nappini S, Giordano F, Genitori L, Mangiafico S. Transvenous embolization: a report of 4 pediatric cases. J Neurosurg Pediatr 2015; 15:445-50. [PMID: 25634817 DOI: 10.3171/2014.11.peds13437] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The treatment of brain arteriovenous malformations (AVMs) in children has always been a challenge for interventionalists, neurosurgeons, and radiosurgeons. Endovascular embolization is usually performed through transarterial access, but in selected cases the transvenous approach can be considered. The authors of this report aimed to evaluate the efficacy of transvenous embolization in very selected pediatric cases. They describe 4 children treated using transvenous embolization for AVMs that were small, had a single drainage vein, and were deeply located or had a difficult arterial access. The 6-month angiographic and clinical follow-ups are reported as well. In all cases, complete occlusion of the AVM was achieved with no side effects for the patient. Transvenous embolization may represent a promising alternative therapeutic option in very selected cases.
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Affiliation(s)
- Leonardo Renieri
- Interventional Neuroradiology Unit, Careggi University Hospital; and
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8
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Spontaneous intracranial hemorrhage in children – ruptured lobar arteriovenous malformations: report of two cases. ROMANIAN NEUROSURGERY 2015. [DOI: 10.1515/romneu-2015-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Brain arteriovenous malformations (AVMs) are lesions thought to be primarily congenital in origin, consisting of fistulous connections of abnormal arteries and veins, without normal intervening capillary beds and no cerebral parenchyma between vessels. In the pediatric population, AVMs represent the most common cause of spontaneous intracranial hemorrhage (ICH), with a high recurrent bleeding risk. The aim of this paper is to report 2 cases of ruptured lobar AVMs in children, presenting with spontaneous ICH. Due to the patients’ neurological status, the only imaging examination performed preoperatively was a CT scan, showing intraparenchymal hemorrhage. Thus, there was no MRI/angiographic examination to prove the existence of a brain AVM prior to the surgical interventions. Also, the cerebral angiography performed after the surgery showed, in both patients, no signs of residual vascular malformations. Therefore, the diagnosis of AVM was certified by macroscopic and microscopic pathological findings, with no brain imaging suggestive of a vascular malformation.
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9
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Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience. J Neurosurg Pediatr 2015; 15:71-7. [PMID: 25360855 DOI: 10.3171/2014.9.peds146] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0-2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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10
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Clinical features and endovascular treatment of intracranial arteriovenous malformations in pediatric patients. Childs Nerv Syst 2014; 30:647-53. [PMID: 24013265 DOI: 10.1007/s00381-013-2277-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to characterize clinical features and evaluate the clinical outcome of endovascular embolization treatment intracranial arteriovenous malformations in pediatric patients. METHODS A cohort of children (age ≤ 18 years) with arteriovenous malformations (AVMs) from 2000 to 2012 was included. Predictors studied included patient gender, age, and angioarchitectural features, including AVM location, nidus morphology and size, venous drainage, and associated aneurysms. Treatment method, complications and outcomes were recorded. The features of AVMs were evaluated before the treatment. RESULTS One hundred twenty-seven children (77 males, mean age 13.2 years) were included; 90/127 (70.9 %) children were presented with hemorrhage. AVM size and deep venous drainage were independently associated with hemorrhage; 66/127 patients (52 %) treated with endovascular embolization. Complete obliteration at the end of all endovascular procedures was achieved in 14/66 patients (21.2 %), with an average of 78 % (range, 20-100 %) volume reduction. A mean of 2.9 (range, 1-9) feeding pedicles was embolized per patient. Overall, nine complications occurred in a total of 123 procedures (7.3 %). There was no procedure-related death in this study population. There was no significant difference between patients with and without complications in terms of AVM grade, demographic characteristics, or embolization features. CONCLUSIONS AVM size and deep venous drainage were independently associated with hemorrhage in pediatric patients. Endovascular procedure is feasible and safe for pediatric AVMs, and complete embolization can be achieved in small AVMs, while large AVMs can be adequately reduced in size for additional microsurgery or stereotactic radiosurgery.
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11
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Soltanolkotabi M, Schoeneman SE, Alden TD, Hurley MC, Ansari SA, DiPatri AJ, Tomita T, Shaibani A. Onyx embolization of intracranial arteriovenous malformations in pediatric patients. J Neurosurg Pediatr 2013; 11:431-7. [PMID: 23394354 DOI: 10.3171/2013.1.peds12286] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients. METHODS All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single children's hospital over a 5-year period were collected and evaluated. RESULTS Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03). CONCLUSIONS Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.
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Affiliation(s)
- Maryam Soltanolkotabi
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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12
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Darsaut TE, Guzman R, Marcellus ML, Edwards MS, Tian L, Do HM, Chang SD, Levy RP, Adler JR, Marks MP, Steinberg GK. Management of pediatric intracranial arteriovenous malformations: experience with multimodality therapy. Neurosurgery 2011; 69:540-56; discussion 556. [PMID: 21430584 DOI: 10.1227/neu.0b013e3182181c00] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Successful management of pediatric arteriovenous malformations (AVMs) often requires a balanced application of embolization, surgery, and radiosurgery. OBJECTIVE To describe our experience treating pediatric AVMs. METHODS We analyzed 120 pediatric patients (< 18 years of age) with AVMs treated with various combinations of radiosurgery, surgery, and endovascular techniques. RESULTS Between 1985 and 2009, 76 children with low Spetzler-Martin grade (1-3) and 44 with high-grade (4-5) AVMs were treated. Annual risk of hemorrhage from presentation to initial treatment was 4.0%, decreasing to 3.2% after treatment initiation until confirmed obliteration. Results for AVM obliteration were available in 101 patients. Initial single-modality therapy led to AVM obliteration in 51 of 67 low-grade (76%) and 3 of 34 high-grade (9%) AVMs, improving to 58 of 67 (87%) and 9 of 34 (26%), respectively, with further treatment. Mean time to obliteration was 1.8 years for low-grade and 6.4 years for high-grade AVMs. Disabling neurological complications occurred in 4 of 77 low-grade (5%) and 12 of 43 high-grade (28%) AVMs. At the final clinical follow-up (mean, 9.2 years), 48 of 67 patients (72%) with low-grade lesions had a modified Rankin Scale score (mRS) of 0 to 1 compared with 12 of 34 patients (35%) with high-grade AVMs. On multivariate analysis, significant risk factors for poor final clinical outcome (mRS ≥ 2) included baseline mRS ≥ 2 (odds ratio, 9.51; 95% confidence interval, 3.31-27.37; P < .01), left-sided location (odds ratio, 3.03; 95% confidence interval, 1.11-8.33; P = .03), and high AVM grade (odds ratio, 4.35; 95% confidence interval, 1.28-14.28; P = .02). CONCLUSION Treatment of pediatric AVMs with multimodality therapy can substantially improve obliteration rates and may decrease AVM hemorrhage rates. The poor natural history and risks of intervention must be carefully considered when deciding to treat high-grade pediatric AVMs.
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Affiliation(s)
- Tim E Darsaut
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5325, USA
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Abstract
INTRODUCTION Pediatric stroke, while increasingly recognized among practitioners as a clinically significant, albeit infrequent entity, remains challenging from the viewpoint of clinicians and researchers. DISCUSSION Advances in neuroimaging have revealed a higher prevalence of pediatric stroke while also provided a safer method for evaluating the child's nervous system and vasculature. An understanding of pathogenic mechanisms for pediatric stroke requires a division of ages (perinatal and childhood) and a separation of mechanism (ischemic and hemorrhagic). This article presents a review of the current literature with the recommended divisions of age and mechanism. CONCLUSION Guidelines for treatment, though limited, are also discussed.
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14
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Lanni G, Catalucci A, Conti L, Di Sibio A, Paonessa A, Gallucci M. Pediatric stroke: clinical findings and radiological approach. Stroke Res Treat 2011; 2011:172168. [PMID: 21603166 PMCID: PMC3095895 DOI: 10.4061/2011/172168] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 02/16/2011] [Indexed: 12/13/2022] Open
Abstract
This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.
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Affiliation(s)
- Giuseppe Lanni
- Department of Neuroradiology, S.Salvatore Hospital, University of L'Aquila, Via Vetoio, Coppito, 67100 L'Aquila, Italy
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15
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Foy AB, Wetjen N, Pollock BE. Stereotactic radiosurgery for pediatric arteriovenous malformations. Neurosurg Clin N Am 2011; 21:457-61. [PMID: 20561495 DOI: 10.1016/j.nec.2010.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Children with intracranial arteriovenous malformations (AVM) have a high cumulative risk of hemorrhage and therefore effective treatment of AVMs in the pediatric population is imperative. Treatment options include microsurgical resection, endovascular embolization, staged or single fraction radiosurgery, or some combination of these treatments, with the ultimate goal of eliminating the risk of hemorrhage. In this article the authors review the current data on the use of radiosurgery for the treatment of childhood AVMs. Factors associated with successful AVM radiosurgery in this population are examined, and comparisons with outcomes in adult patients are reviewed.
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Affiliation(s)
- Andrew B Foy
- Department of Neurologic Surgery, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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16
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Radiosurgical management of pediatric arteriovenous malformations. Childs Nerv Syst 2010; 26:1359-66. [PMID: 20607249 DOI: 10.1007/s00381-010-1207-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/12/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Hemorrhage from an arteriovenous malformation (AVM) is the commonest cause of childhood stroke. Management options for children include observation and medical management, surgical resection, endovascular embolization, or stereotactic radiosurgery, alone or in combination. METHODS Radiosurgery is used for high-risk malformations in critical brain locations. While this goal is being achieved, there should be limited morbidity and hopefully no mortality from hemorrhage or radiation-induced brain injury. RESULTS Physicians who consider AVM radiosurgery cite one or more of the following: (1) that radiosurgery is an effective therapy required for the management of deep-brain AVMs; (2) that radiosurgery is an effective therapy for residual AVMs after subtotal resection; (3) that radiosurgery is worthwhile in an attempt to lower management risks for AVMs in functional brain locations; (4) since embolization does not cure most AVMs, additional therapy such as radiosurgery may be required; and (5) microsurgical resection may not be the best choice for some children. CONCLUSION Radiosurgery is the first and only biologic AVM therapy; it represents the beginnings of future cellular approaches to vascular malformation diseases. For this reason, the future of radiosurgery may be impacted positively by the development of other biologic strategies such as brain protection or endothelial sensitization.
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Rubin D, Santillan A, Greenfield JP, Souweidane M, Riina HA. Surgical management of pediatric cerebral arteriovenous malformations. Childs Nerv Syst 2010; 26:1337-44. [PMID: 20596869 DOI: 10.1007/s00381-010-1211-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 06/12/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are the most common cause of intracerebral hemorrhage in children. Different options exist for their successful management consisting of surgery, endovascular embolization, stereotactic radiosurgery, or a combination of these treatments. DISCUSSION In this paper, we discuss the different treatment modalities in the treatment of pediatric cerebral AVMs emphasizing the role of surgery and endovascular embolization as a preoperative strategy.
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Affiliation(s)
- David Rubin
- Department of Neurological Surgery,Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Neurophysiologic Intraoperative Monitoring of Pediatric Cerebrovascular Surgery. J Clin Neurophysiol 2009; 26:85-94. [DOI: 10.1097/wnp.0b013e3181a03381] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER. Management of Stroke in Infants and Children. Stroke 2008; 39:2644-91. [PMID: 18635845 DOI: 10.1161/strokeaha.108.189696] [Citation(s) in RCA: 743] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Jankowitz BT, Vora N, Jovin T, Horowitz M. Treatment of pediatric intracranial vascular malformations using Onyx-18. J Neurosurg Pediatr 2008; 2:171-6. [PMID: 18759597 DOI: 10.3171/ped/2008/2/9/171] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Onyx-18 is a relatively new liquid embolic agent. The initial success with this polymer will result in increased utilization in children, but its use and safety in the pediatric population have not been firmly established. METHODS Between December 2005 and January 2008, the cerebral vascular malformations in 6 children were embolized using Onyx-18. The ages of the patients ranged from 1 day to 12 years. Pathological types of the vascular malformations included 4 arteriovenous malformations and 2 vein of Galen malformations. Clinical presentations included intracranial hemorrhage in 2 patients, papilledema in 1 patient, and high-output heart failure in 3 patients. RESULTS In 6 pediatric patients, 21 embolization procedures were performed utilizing a combination of Onyx-18, platinum coils, and Embosphere microspheres. The average estimated size reduction for the arteriovenous malformations was 60%. Total obliteration of a malformation was achieved in 1 patient. Two patients received adjuvant radiosurgery. Of the 2 vein of Galen malformations, one was completely embolized and the other had an approximately 50% reduction in flow. No open surgical intervention was used. Clinical follow-up ranged from 7 to 12 months. Angiographic follow-up data were obtained at 1, 6, and 7 months in 3 patients, whereas 1 patient awaits repeat angiography. Complications included a transient monoparesis with complete resolution in 1 patient. Two patients died within 24 hours of an embolization procedure due to intracranial hemorrhages. CONCLUSIONS Onyx-18 is a feasible embolization agent for use in intracranial vascular malformations in the pediatric population, but long-term follow-up data will be necessary to assess the continued efficacy and safety of this agent.
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Affiliation(s)
- Brian T Jankowitz
- Department of Neurosurgery, Minimally Invasive endoNeurosurgery Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Lee JW, Kim DS, Shim KW, Chang JH, Huh SK, Park YG, Choi JU. Management of intracranial cavernous malformation in pediatric patients. Childs Nerv Syst 2008; 24:321-7. [PMID: 17876588 DOI: 10.1007/s00381-007-0465-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Cavernous malformations (CMs) are vascular malformations affecting any part of the central nervous system. CMs in the pediatric age group are known to be different from those of adults both in origin and clinical characteristics. In this paper, we report our experience in managing CMs in pediatric patients. MATERIALS AND METHODS Between January 1994 and December 2006, 33 patients younger than 20 years of age with intracranial CMs were treated with microsurgery or radiosurgery. We retrospectively reviewed the presentation and treatment of these 33 patients (18 boys and 15 girls; average age 11.6 years). RESULTS The most common symptom at presentation was seizure (19 children, 57.6%). The most common type of CM, classified on the basis of magnetic resonance imaging, was type II (18, 54.5%). The supratentorial compartment was the most frequent location (27, 71.8%), and only six CMs (18.2%) were observed in the infratentorial compartment. Microsurgery was performed on 25 patients (75.8%), and radiosurgery was performed on eight patients (24.2%). The overall post-treatment results were positive. Only two children (6.1%) had persistent presurgical neurological signs, although the treatment ameliorated them. No progression of the preoperative neurological signs or onset of new neurological deficits was seen in any of the patients. In our patient group, the microsurgical removal of CMs resulted in the prevention of recurrent hemorrhage and the control of seizure disorders in all cases. CONCLUSIONS Our results suggest that pediatric patients with symptomatic CMs should be treated surgically because of the risk of recurrent hemorrhaging and the general benefits of CM removal.
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Affiliation(s)
- Jae-Whan Lee
- Department of Neurosurgery, Brain Korea 21 Project for Medical Science, Brain Research Institute, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul 120-752, South Korea
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Bristol RE, Albuquerque FC, Spetzler RF, Rekate HL, McDougall CG, Zabramski JM. Surgical management of arteriovenous malformations in children. J Neurosurg 2006; 105:88-93. [PMID: 16922068 DOI: 10.3171/ped.2006.105.2.88] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Children compose 3 to 20% of the patients with arteriovenous malformations (AVMs); however, AVMs are responsible for 30 to 50% of intracranial hemorrhages in children. METHODS The medical records of 82 children with 84 AVMs treated surgically between 1983 and 2005 were reviewed. Fifty-two patients (63%) presented with hemorrhage, 13.4% presented with seizures, and AVMs in 12% were found incidentally. Patients with brainstem lesions presented at a significantly younger age (p = 0.002) than those harboring lesions in other locations. Frontal lobe lesions were significantly smaller than those in other locations, and thalamic lesions were significantly larger (p = 0.012 and 0.005, respectively). Most patients with Spetzler-Martin Grades I to III lesions underwent craniotomy only. Half of the patients with Grade IV and V lesions underwent embolization, craniotomy, and radiosurgery. The mean follow-up period was 43 months. Postoperatively, the initial obliteration rate was 65%, with a long-term obliteration rate of 90%. The perioperative mortality rate was 3.7%. Altogether, 81% of patients had excellent outcomes, and patients with Grade I lesions had the best outcomes. Of the 52 patients who presented with hemorrhage, 17% had fair or poor outcomes. The recurrence rate was 5.6%. CONCLUSIONS Children with AVMs may be more prone than adults to present with a hemorrhage and to experience recurrence of the lesion after treatment. The authors favor resection for most AVMs in children and use embolization as a preoperative strategy for Grades II to V lesions treated surgically. Prehemorrhagic Grade IV and V lesions may best be treated conservatively and observed carefully for the development of symptoms. Long-term follow up of all patients is essential.
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Affiliation(s)
- Ruth E Bristol
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Abstract
OBJECT The authors present the results of stereotactic radiosurgery performed in a consecutive series of children with arteriovenous malformations (AVMs) and analyze factors associated with successful radiosurgery for this condition. METHODS Between 1990 and 2001, 38 patients 18 years of age or younger underwent radiosurgery for AVMs. The median patient age was 15 years; 20 patients (53%) had experienced a prior hemorrhage. Twenty-seven AVMs (71%) were Spetzler-Martin Grade III or higher; 16 patients (42%) had AVMs located in the basal ganglia, thalamus, or brainstem. The median AVM volume was 3.4 cm3. The median radiosurgery-based AVM score was 1.08 according to the following formula: AVM score = 0.1 volume (cm3) + 0.02 x age (years) + 0.3 x location (frontal/temporal = 0; parietal/occipital/corpus callosum/cerebellar = 1; basal ganglia/thalamus/brainstem = 2). The median follow-up period was 42 months. One patient (3%) had an intraventricular hemorrhage 26 months after radiosurgery but experienced no new deficit. No patient had a permanent radiation-related complication after radiosurgery. Twenty-six patients (68%) had excellent outcomes (as defined by complete obliteration of the AVM with no new deficit) after radiosurgical treatment (21 cases determined using angiography and five using magnetic resonance imaging). Twelve patients (32%) remained unchanged (incomplete obliteration but no new deficit). Univariate analysis found that patient age, AVM volume, location, or Spetzler-Martin grade did not correlate with excellent outcomes. Patients whose radiosurgery-based AVM scores were 1 or lower experienced an excellent outcome more frequently than patients with an AVM score higher than 1 (88% compared with 52%, p = 0.03). CONCLUSIONS Radiosurgery was successful in the treatment of the majority of pediatric patients suffering from AVMs, and morbidity levels were minimal. The radiosurgery-based AVM grading scale accurately predicted these outcomes. Children whose AVMs are obliterated after radiosurgery should undergo repeated angiography after they reach adulthood to rule out the possibility of a recurrent nidus that would expose them to an ongoing risk of hemorrhage.
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Affiliation(s)
- Aaron A Cohen-Gadol
- Departments of Neurologic Surgery and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Abstract
BACKGROUND Childhood stroke is increasingly recognized as an important cause of morbidity and mortality. Risk factors for stroke in childhood are different than those traditionally seen in adults. REVIEW SUMMARY This review summarizes, in brief, the epidemiology, risk factors, evaluation, treatment, outcome, and recurrence risk of children with arterial ischemic stroke (AIS). Areas of controversy and those that require further study are highlighted. Tables summarizing important points of the history, physical examination, and diagnostic evaluation of AIS are provided. CONCLUSIONS Children with stroke should be carefully evaluated for risk factors and possible etiology of stroke. At the present time, treatment is based upon extrapolation from the adult literature and expert opinion, as no evidence-based guidelines exist, except in sickle cell anemia. International, multicenter trials are beginning and should provide some answers over the next few years.
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Affiliation(s)
- Lori C Jordan
- Johns Hopkins Hospital, Department of Neurology, Baltimore, Maryland, USA.
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Lynch JK, Pavlakis S, Deveber G. Treatment and prevention of cerebrovascular disorders in children. Curr Treat Options Neurol 2006; 7:469-80. [PMID: 16221370 DOI: 10.1007/s11940-005-0047-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Cerebrovascular disorders are an important cause of mortality and chronic morbidity in children. Ischemic stroke is more common than cerebral venous thrombosis and hemorrhagic stroke in children. Several medical disorders have been associated with stroke in children, and a thorough evaluation of underlying causes is needed to determine the best treatment and prevention strategy. The treatment and prevention of stroke in children is not well studied, and current recommendations are based on adult studies, nonrandomized trials, or expert opinion. Children with stroke require immediate, special attention and if possible should be stabilized and transferred to an institution that can offer pediatric neurovascular expertise and care. All children with stroke should be referred to or have their care managed by a pediatric neurologist. The treatment of stroke in adults is well studied, and when applicable this evidence should be considered in the treatment of children with stroke. Data from animal and adult stroke studies have demonstrated a benefit for the aggressive treatment of infection, fever, blood pressure, hypo/hyperglycemia, intracranial pressure, and seizures, and should be applied to children with stroke. The use of thrombolytic, antithrombotic, and antiplatelet therapies is based on adult studies, cohort studies, and/or expert opinion. Two consensus guidelines regarding the treatment of arterial ischemic stroke and cerebral venous thrombosis were recently published and recommend the use of anticoagulants or antiplatelet agents in the acute setting, depending on the underlying cause of stroke. The evidence for the primary prevention of stroke in children is restricted to sickle cell disease (SCD) and derived from the Stroke Prevention in Sickle Cell Study Project studies. Long-term chronic transfusion therapy to maintain hemoglobin S levels below 30% is indicated in children with SCD and intracranial stenosis. It has also been recently determined that chronic transfusion therapy should not be stopped in children with SCD and an increased risk for stroke. The recurrence rate of arterial ischemic stroke (AIS) in children ranges from 6% to 30% and is highest among children with recurrent transient ischemic attack, cardiac disease, arteriopathies, and metabolic and coagulation abnormalities. Recommendations for secondary prevention are based on adult studies and the underlying pathophysiology of the stroke. Antiplatelet therapy (aspirin 1-5 mg/kg/day) is recommended in most children with a history of AIS. Although there is minimal evidence to support its use in children, anticoagulation may be indicated in AIS associated with extracranial arterial dissection, prothrombotic disorders, cardiac disease, severe intracranial stenosis, and recurrent AIS while on antiplatelet therapy.
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Lawton MT, Vates GE, Quinones-Hinojosa A, McDonald WC, Marchuk DA, Young WL. Giant infiltrative cavernous malformation: clinical presentation, intervention, and genetic analysis: case report. Neurosurgery 2005; 55:979-80. [PMID: 15934180 DOI: 10.1227/01.neu.0000137277.08281.48] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Cavernous malformations can present in children with a sporadic course of repeated hemorrhage and enlargement, but they are rarely aggressive, infiltrative, or multilobar. We present the case of a young boy with a complex cavernous malformation that evolved during the course of a decade to encompass the majority of his right cerebral hemisphere. CLINICAL PRESENTATION A 16-month-old boy presented with seizures, and radiographic studies demonstrated a large cavernous malformation in his right frontal pole. During the next 10 years, his seizures became intractable, and he developed progressive left hand weakness and atrophy. His malformation infiltrated his entire right frontal lobe as well as portions of his right parietal lobe, temporal lobe, and deep gray matter structures. INTERVENTION The patient underwent right hemicraniotomy and near total resection of the lesion. Pathological analysis revealed dilated, thin-walled vessels separated by small amounts of intervening astrogliotic brain consistent with cavernous malformation. The patient recovered to his baseline neurological condition and has had no seizure or hemorrhage since his operation. Genetic testing did not reveal mutations in either the CCM1 (KRIT1) or CCM2 (malcavernin) genes. CONCLUSION This case may represent an atypical variant of cavernous malformation best termed giant infiltrative cavernous malformation. Despite its unusual size, multilobar location, and aggressive infiltration, it can be managed effectively with standard surgical resection.
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Affiliation(s)
- Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Kiriş T, Sencer A, Sahinbaş M, Sencer S, Imer M, Izgi N. Surgical results in pediatric Spetzler-Martin grades I-III intracranial arteriovenous malformations. Childs Nerv Syst 2005; 21:69-74; discussion 75-6. [PMID: 15322842 DOI: 10.1007/s00381-004-1025-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2004] [Revised: 03/10/2004] [Indexed: 10/26/2022]
Abstract
OBJECTS The goal of cerebral arteriovenous malformation (AVM) therapy in pediatric patients should be complete resection or obliteration of the AVM to eliminate subsequent hemorrhage, because of high mortality and morbidity rates related to hemorrhage in addition to the longer life expectation. Despite advances in Gamma knife radiosurgery and in endovascular embolization, surgical resection is still the gold standard for treating cerebral AVMs. METHODS Between 1986 and 2003, 20 children were surgically treated for cerebral AVMs. The AVMs were graded I, II, and III using the Spetzler-Martin (S-M) Grading Scale. Good recovery was achieved in 18 out of 20 patients (90%) and only 1 patient was moderately disabled (5%). There was one mortality (5%) related to the preoperative deep comatose state of the patient. The total obliteration rate was 89% (17 out of 19). CONCLUSION For S-M grade I-III AVMs, surgical resection is the treatment of choice, considering its high cure rate and low morbidity and mortality rates.
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Affiliation(s)
- Talat Kiriş
- Department of Neurosurgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey.
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