Complications of Therapies for Dural Arteriovenous Fistulas in Children

Surgical

As with any surgical intervention, there are risks. In addition to hemorrhage, infection and CSF leaks, and seizure, there are some specific threats inherent to redirecting cerebral blood flow including:

• Massive blood loss: This is especially important in the younger children.
• Thrombosis of normal venous outflow and venous infarction: It is important to preserve normal drainage to the brain. A thorough study of preoperative imaging is a must in order to avoid this complication.
• Cranial nerve deficits: Probably more frequent after endovascular embolization of arteries that also supply the cranial nerves rather than with open surgery.
• Hydrocephalus: Uncommon. You should watch for signs of intracranial pressure and rule out intra-ventricular hemorrhage. An external ventricular drain might be necessary to temporarily control hydrocephalus.
• Normal perfusion pressure breakthrough: Although probably less frequent than with AVMs, swelling and neurological deficit can appear after blood flow is recanalized through new channels after treatment. Tight blood pressure control is key to control this phenomenon.

• Recurrence and progression: DAVFs are dynamic lesions. Even with complete resection they might recurred

Medical

• Decompensation of heart function: This could range from increased tiredness to pulmonary edema.
• Digitalis intoxication: This could manifest such as nausea, vomiting diarrhea. Other symptoms include xanthopsia, bradycardia and even seizures. Levels of digoxin should be monitored.

Radiation

• Radiation injury: Radiation exposure from multiple long-term embolization sessions and/or radiosurgery in case of multimodality management can cause permanent injury to the brain.
• Damage of healthy brain: Occurs in 2%–10% of patients after radiosurgery and can manifest in many different ways (from focal deficit to cognitive impairment) (26).
• Delayed malignancies: After radiation therapy, including radiosurgery, there is a low risk of developing secondary malignancies of the brain.