title: Use of intraoperative Doppler ultrasound with neuronavigation to guide arteriovenous malformation resection: a pediatric case series.
abstract: OBJECTIVE
  Over the last 20 years, several intraoperative adjuncts, including ultrasonography, neuronavigation, and angiography, have been said to aid the intraoperative localization and resection of cerebral arteriovenous malformations (AVMs). The authors assessed the value of intraoperative Doppler ultrasonography in conjunction with neuronavigation during surgery for cerebral AVMs in the pediatric population.
  
  
  METHODS
  The authors reviewed all cranial AVM resections performed by a single surgeon at their institution in the period from 2007 to 2013 and here describe their experience and results in a series of 20 consecutive AVM resections in 19 pediatric patients. Intraoperative Doppler ultrasonography had been used in conjunction with preoperative CT or neuronavigational MRI. Preoperative and postoperative clinical findings, patient age, and Spetzler-Martin AVM grade were identified in all patients.
  
  
  RESULTS
  All patients, whose ages ranged from 2 to 16 years, underwent craniotomy and excision of an AVM, which was supratentorial in 18 cases and infratentorial in 2. Patients in 11 cases underwent preoperative embolization, and all other patients underwent cerebral angiography prior to surgery, except for 2 patients who were urgently surgically treated because of low Glasgow Coma Scale scores and associated hematoma. Spetzler-Martin Grades I (3 cases), II (6), III (7), and IV (4) AVMs were represented in this series. Intraoperative Doppler ultrasound provided high-quality images in all cases and demonstrated the location, size, and flow characteristics of the AVM and any associated hematoma. Delayed postoperative cerebral angiography demonstrated successful AVM resection in all cases. An assessment of clinical outcomes revealed no new long-term neurological deficits at 3 months postoperatively.
  
  
  CONCLUSIONS
  Intraoperative Doppler ultrasonography is a reliable and useful tool for intraoperative localization and guidance for AVM resection in the pediatric population. When used in conjunction with neuronavigation equipment and modern microscopes, this technique has shown a very high complete resection rate with extremely low associated morbidity.
authors.affiliation: Departments of Neurosurgery and Neuroradiology, Royal Manchester Children's Hospital, Manchester, United Kingdom.
authors.forename: James S
authors.initials: JS
authors.lastname: Walkden
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Zador
authors.forename: Amit
authors.initials: A
authors.lastname: Herwadkar
authors.forename: Ian D
authors.initials: ID
authors.lastname: Kamaly-Asl
mesh_terms: D000293:Adolescent; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D007223:Infant; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging* / Q000601:surgery* / Q000628:therapy; D008297:Male; D008853:Microscopy; D016343:Monitoring, Intraoperative / Q000379:methods*; D038361:Neuronavigation / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods*; D018615:Ultrasonography, Doppler, Color; D014656:Vascular Surgical Procedures / Q000379:methods*
keywords: AVM = arteriovenous malformation; DSA = digital subtraction angiography; Doppler ultrasonography; GCS = Glasgow Coma Scale; MCA = middle cerebral artery; SM = Spetzler-Martin; arteriovenous malformation; intraoperative ultrasound; mRS = modified Rankin Scale; neuronavigation; pediatric; vascular disorders