109. Surgical Strategies for Management of Ruptured Pediatric Arteriovenous Malformations: the Role of Initial Decompressive Craniectomy
Award: Top Poster
Authors: Melissa Ann LoPresti, MD; Eric Goethe, MD; Sandi Lam (Houston, TX)
Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. 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 regards to clinical outcomes and recovery.
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 decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined with primary outcomes measured including functional status, AVM obliteration rate, AVM recurrence/residual, and rehemorrhage.
36 cases were included; 28 (77.8%) underwent initial AVM resection, seven (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 associated with a higher mean hematoma volume (52.9 vs 22.2mL, p<0.01), larger mean midline shift (5.1 vs 2.1mm, 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, and functional outcomes. AVM recurrence and undergoing additional procedures was associated with the group treated by initial craniectomy followed by interval resection.
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 over children who undergo AVM resection alone. This is reasonable in those with large volume hematomas, significant midline shift, and cisternal effacement concerning for 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.