Long-Term Outcomes after Endovascular Oblitraion of Pediatric Arteriovenous Malformation : A Multi-Center Analysis

BACKGROUND: Although pediatric arteriovenous malformations (AVMs) are relatively rare, they carry a higher rate of rupture than in adults. Pediatric AVMs could also present with recurrent seizures or headaches. Endovascular embolization is usually achievable in pediatric AVMs with increasing complete obliteration rates, especially in cases with small AVMs. It also serves as adjuvant therapy with microsurgery or radiosurgery in larger AVMs. Long-term follow-up is required to confirm the efficiency of endovascular AVM obliteration, especially in young populations with the longest life expectancy. OBJECTIVE: The aim of the study was to perform a multicenter analysis of embolized pediatric cerebral AVMs regarding the clinical and radiological outcomes with a long term follow up. METHODS: A retrospective study of 57 pediatric patients diagnosed with cerebral AVMs and admitted to departments of neurosurgery at Alexandria, Sohag and Tanta University hospitals was conducted. All patients were subjected to clinical and radiological assessments. Endovascular embolization was done for all cases in one or two sessions. Complementary treatment included microsurgery and radiosurgery. Clinical and radiological follow-ups were done for all patients for at least one year. The outcome measures were angiographic disappearance of the AVM nidus and neurological improvement on clinical follow-up. RESULTS: The study included 57 pediatric patients with age range between 4-18 years. Fifty-four patients (94.73%) presented with intracranial hemorrhage and 3 patients (5.26%) presented with seizures. All patients were treated with endovascular embolization as a primary modality of treatment. Total obliteration of the AVM was achieved in one session in 30 patients (52.63%) and in 2 sessions in 8 patients (14.03%). After endovascular embolization, 7 patients (12.28%) underwent microsurgical excision, and another 12 patients (21.05%) were referred to radiosurgery. All patients had no permanent morbidity or mortality related to the embolization technique. Five patients (8.77%) had transient neurological deficits. One patient had minimal subarachnoid hemorrhage (SAH) due to microwire perforation and another patient had temporary pulmonary edema due to the effect of dimethyl sulfoxide on lung; both patients improved with medical treatment. One patient had a retained tip of a microcatheter which was removed with surgery. CONCLUSION: Endovascular embolization is a safe and effective technique as a single modality in the management of pediatric AVMs. It has extended the role of microsurgery and radiosurgery to treat previously non-curable high-grade lesions. Long-term follow-up over 3 years confirms stable occlusion. A longer follow-up is still needed due to the long life expectancy.