Management of Cerebral Arteriovenous Malformations in Children

Initial Management at Presentation

• Initial management predicated on presentation: If the child presents with a hemorrhage or is acutely symptomatic, urgent intervention is often warranted. If the child has an AVM found incidentally, evaluation can proceed in a nonemergent fashion, with concomitant discussion about treatment options with the family.
• Decision based on risk-benefit analysis: Although no definitive guidelines exist, there is consensus that obliteration of cerebral AVMs in children is justified if the risk of treatment is considered less than the risk of hemorrhage. Surgery is often cited as a first-line treatment, although growing experiences with radiosurgery and, to a lesser extent, embolization, are increasing the breadth of treatment options.

Adjunctive Therapies

• Embolization: Surgery and radiosurgery are considered primary treatments for AVM. Embolization can be a useful adjunct for enhancing the efficacy of these two treatments, but embolization as a stand-alone treatment for AVMs remains controversial (21). The durable cure rate is difficult to ascertain, and children have an elevated risk of recurrent AVM.

Follow-up

• Annual office visit: Postoperative care frequently consists of an office visit about 1 month postoperatively and annually thereafter.
• Imaging: MRI/MRA including gadolinium contrast is recommended during follow-up visits for the first 5 years. Consider DSA 1 year after treatment. Although there is a low level of risk from DSA, MRI follow-up represents an attractive lower risk and likely lower cost strategy for longer term follow-up, with a DSA being performed when there is suspicion of recurrence of the AVM on MRI — often first detected as new contrast enhancement in the resection cavity. See Follow-up for Cerebral Arteriovenous Malformations in Children for more details on follow-up imaging.