Clinical Fellow Boston Children's Hospital Los Angeles, California, United States
Introduction: Arteriovenous malformations (AVMs) are a leading cause of spontaneous intracranial hemorrhage in pediatric patients. Management after rupture can involve emergent surgery or conservative management of acute symptoms with delayed surgical resection.
Methods: A vascular database at Boston Children’s Hospital was retrospectively reviewed for all patients with a diagnosis of AVM. All relevant clinical and radiographic data was reviewed and primary endpoints included timing of surgery (early, < 4 weeks after rupture vs. late, >= 4 weeks after rupture) and rate of re-hemorrhage prior to surgery.
Results: A total of 150 patients met inclusion criteria of AVM and 91 patients (60.7%) presented with rupture. Of those that presented with rupture, 35 (38.5%) required early intervention (median 0.9 weeks, IQR0.05-2.5 weeks) and 56 (61.5%) underwent surgery in a delayed fashion (median 12.45 weeks, IQR6.5-20.8 weeks) after rupture. Only 1 patient (1%) presented to our facility with re-hemorrhage 8.1 weeks after initial rupture at an outside facility-this patient had an intranidal aneurysm and our current practice pattern would not delay treatment for this child, as this is a known early rebleed risk factor. The early intervention group had a worse mRS score (2 vs. 1, p=0.02) on presentation. Between the early and late cohorts, presence of IVH (51.4% vs. 46.4%, p=0.65), seizures (9% vs. 10.7%, p=0.74), hydrocephalus (14.3% vs. 16.1%, p=0.81), size greater than 3cm (14.8% vs. 8%, p=0.38) and Spetzler Martin grade difference was not statistically significant.
Conclusion : Earlier intervention for AVM rupture is indicated for patients with greater initial disability or high risk AVM features. Otherwise, surgical intervention can safely be delayed for at least 4-8 weeks after initial rupture which allows for referral to a high-volume center and benefit of a more relaxed brain with better visualization of the nidus, with minimal risk of repeat hemorrhage in the interim.
