Complications of Therapies for Cerebral Arteriovenous Malformations in Children

Surgical

• Bleeding: Bleeding is the most immediate complication of surgery. Risks are magnified in smaller children, who have little reserve and in whom the loss of one-quarter of their blood volume could lead to hypovolemic shock (101,125). Such patients may experience rapid decompensation, which mandates careful monitoring and replacement of blood products by the operative team.
• Neurological deficits: Neurological deficits can occur after AVM resection, although specific rates are hard to derive, given the wide variability in AVM size and location.

Other

• Embolization has complication rates of 6.7% to 26.3%: Small cohort studies of children undergoing endovascular embolization for an AVM have reported complication rates of 6.7% to 26.3%; complications include nontarget embolization, ischemic stroke, hemorrhage, and vessel perforation (103,104,105,106).
• Radiation therapy complications include bleeding after treatment: The long delay between treatment and lesion obliteration in radiosurgery for AVMs means that the child is at risk of bleeding during this interval. Patients with small (<3 cm in diameter), deep-seated lesions (in the basal ganglia, internal capsule, and thalamus) are the best candidates for radiosurgery. A study of 42 children with lesions in these locations documented a 62% angiographic cure rate within 2 years (107). However, radiosurgery of AVMs in these sites has yielded a higher risk of rebleeding when compared to AVMs treated in other areas of the brain (108).
• Risk of radiation injury: Young children are at increased risk of radiation-induced damage, including injury to the surrounding developing brain, and potential development of secondary malignancies (109). These risks limit radiation use to older children in most cases.