Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy
Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children.
A retrospective chart review was conducted examining patients age 0–18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage.
Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures.
Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
KeywordsPediatric arteriovenous malformation Arteriovenous malformation rupture Decompressive craniectomy Arteriovenous malformation resection
Glasgow Coma Scale
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author declares that no conflict of interest exists.
The authors have no conflicts of interest to disclose.
No part of this work has been previously published.
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