title: Management of pediatric intracranial arteriovenous malformations: experience with multimodality therapy.
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).
  
  
  CONCLUSIONS
  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.
authors: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5325, USA.
authors: Tim E
authors: TE
authors: Darsaut
authors: Raphael
authors: R
authors: Guzman
authors: Mary L
authors: ML
authors: Marcellus
authors: Michael S
authors: MS
authors: Edwards
authors: Lu
authors: L
authors: Tian
authors: Huy M
authors: HM
authors: Do
authors: Steven D
authors: SD
authors: Chang
authors: Richard P
authors: RP
authors: Levy
authors: John R
authors: JR
authors: Adler
authors: Michael P
authors: MP
authors: Marks
authors: Gary K
authors: GK
authors: Steinberg
mesh_terms: D000293:Adolescent; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000473:pathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D008297:Male; D008866:Microsurgery; D019635:Neurosurgical Procedures; D016634:Radiosurgery; D012307:Risk Factors; D012421:Rupture; D016019:Survival Analysis; D016896:Treatment Outcome