Outcome of Therapies for Cerebral Arteriovenous Malformations in Children

Outcome After Surgery

• 82% to 90% good outcome, 0% to 5% mortality: In children with Spetzler-Martin grades 1-3 whose AVMs were treated by surgical resection, favorable neurological outcomes (according to modified Rankin Scale score) were achieved in 86.1% to 90% of patients; deaths occurred at rates of 2.8% to 5%, with radiographic obliteration rates of 89% to 100% (110,111). In a large cohort of 111 children with AVMs and Spetzler-Martin grades 1-5, favorable neurological outcomes were achieved in 82.0% of patients with no deaths, although 7.2% of patients had postoperative disabilities (modified Rankin Scale > 2) (112). The radiographic obliteration rate was 100% (112). Predictors of long-term disability were pretreatment modified Rankin Scale and the presence of flow-related aneurysms (112).

Outcome After Radiation Therapy

• Lower rates of obliteration and favorable outcomes: For comparison, large studies evaluating the outcomes of pediatric patients with AVMs treated with radiosurgery reported obliteration rates of 64.3% to 65.8% and favorable outcomes in 59% of patients (113,114,115). High-grade (Spetzler-Martin grade 4) AVMs treated with radiosurgery have been associated with a 35% obliteration rate (at 10 years) and 35.7% favorable outcomes (116).
• Complications of radiosurgery: A large meta-analysis reported overall complication rates of radiosurgery for pediatric AVMs as 8.0%, including new neurological deficit rates of 3.1% and rehemorrhage rates of 4.2% (114).

Outcome After Multimodality Therapy

• Team includes neurointerventionalists, radiation oncologists, and neurosurgeons: Multimodality therapy of AVMs has been advocated by several investigators (10,40,96,117,118[p199],119). In this approach, neurointerventionalists, radiation oncologists, and neurosurgeons work together to determine the best strategy for a particular patient.
• Low complication rates and good outcomes: A large meta-analysis reported pooled complication rates of 5.7% for embolization plus surgery and 10.3% for embolization plus radiosurgery, with obliteration rates of approximately 70% and good neurological outcomes (modified Rankin Scale ≤ 2) in more than 90% of patients (40). The high likelihood of obliteration and low complication rates associated with this approach make a convincing argument in favor of multimodality treatment of pediatric AVMs.