title: Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Gross
authors.forename: Armide
authors.initials: A
authors.lastname: Storey
authors.forename: Darren B
authors.initials: DB
authors.lastname: Orbach
authors.forename: R Michael
authors.initials: RM
authors.lastname: Scott
authors.forename: Edward R
authors.initials: ER
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D001900:Boston; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery / Q000628:therapy*; D008297:Male; D008866:Microsurgery; D019635:Neurosurgical Procedures / Q000379:methods*; D011183:Postoperative Complications / Q000601:surgery; D016634:Radiosurgery; D012189:Retrospective Studies; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*
keywords: AVM; AVM = arteriovenous malformation; angiography; arteriovenous malformation; embolization; mRS = modified Rankin Scale; microsurgery; pediatric; surgery; vascular disorders