Cerebral Arteriovenous Malformations in Pediatric Age:A Clinical Analysis of 164 Consecutive Cases

Oh, Jae Keun; Jung, Jin Young; Lee, Jae Whan; Huh, Seung Kon; Kim, Dong Ik; Park, Young Gou; Lee, Kyu Chang

Abstract

OBJECTIVE
This study was designed to understand the clinical characteristics and to establish therapeutic options for arteriovenous malformations (AVM) in a pediatric age (1~8 year old) group.
METHODS
We reviewed programmed clinical data, patients'medical records and imaging studies of the 164 pediatric AVM patients who were managed at Yonsei University Medical Center from 1975 to 2004. Clinical presentation, location, Spetzler-Marin grade, treatment modality and outcomes were analyzed.
RESULTS
Ninety-one patients (55.5%) were male and seventy-three (44.5%) were female. The most common presenting symptom was hemorrhage (119 patients, 72.6%). In others the symptoms were seizure (26 patients, 15.9%), hemorrhage with seizure (6 patients, 3.6%), focal deficit (4 patients, 2.4%), headache (8 patients, 4.9%) and incidental (1 patients, 0.6%). The locations of AVMs were cerebral convexity (110 patients, 67.1%; 21 frontal, 40 parietal, 23 temporal, 23 occipital), basal ganglia and thalamus (24 patients, 14.6%), corpus callosum (12 patients, 7.3%), sylvian (3 patients, 1.8%), cerebellum (13 patients, 7.9%) and two patients had brain stem lesions (1.2%). According to the Spetzler-Martin grading system, at admission grade II and III AVMs were the most common lesions in our series (43.9% and 33.5%, respectively). The patients were treated with microsurgery in 70 patients (42.7%), radiosurgery in 87 patients, (53.0%), combined treatment in 5 patients (3.1%) and embolization in only 2 patients (1.2%). The average follow-up period was 4.8 years and the overall outcome was considered good in 139 patients (84.8%), fair in 18 patients (11.0%), and poor in 4 patients (2.4%), with 3 patients having died (1.8%). The causes of unfavorable outcomes were initial insult (4 patients), radiation necrosis (1 patient), bleeding during the latent interval (1 patient) and systemic complication (1 patient).
CONCLUSION
Hemorrhagic presentation and deep brain (thalamus and ganglia) lesions were more common in the pediatric patients compared to adult patients. The treatment of choice for hemorrhagic pediatric AVMs is surgical excision, even for deep seated or eloquent area lesions. Radiosurgery is recommended especially for the non-hemorrhagic lesions, particularly in deep seated or eloquent area lesions. Regular imaging studies are necessary for detection of AVM regrowth, and signs of hemorrhage should be monitored during the latent period.