Clinical experience in the microsurgery for the treatment of hemorrhagic arteriovenous malformation of children
Objective To explore the clinical effect of microsurgery in the treatment of hemorrhagic intracranial arteriovenous malformation(AVM)in children.Methods The clinical data of 34 children with hemorrhagic intracranial AVM who underwent microsurgery at the Department of Neurosurgery,the First Affiliated Hospital of Zhengzhou University from June 2017 to June 2022 were retrospectively analyzed.The preoperative Spetzler-Martin score(SMG)was 1 in 4 cases,2 in 11 cases,3 in 13 cases,and 4 in 6 cases.All children underwent craniotomy for resection of cerebral vascular malformations and hematoma evacuation,and the appropriate surgical plan was selected according to the indications.A head CT examination was performed on the first day after the operation to evaluate whether there was intracranial hemorrhage and brain tissue swelling.A head MR examination was performed one week after the operation to evaluate whether there was any residual vascular malformation.The Glasgow coma scale(GCS)was used to evaluate the postoperative improvement of consciousness disorder of the children.Children were followed up in outpatient clinics or by telephone,and cranial MRI or whole-brain DSA was performed 3 and 6 months after surgery to evaluate whether there was residual or recurrence of vascular malformations.The modified Rankin scale score(mRS)was used to evaluate the recovery of neurological function in children and the mRS of 0-1 was considered as good outcome.According to the preoperative SMG grading,the patients were divided into SMG≤3 group and SMG＞3 group,and the outcome difference between the two groups of surviving children was analyzed.Results The operations of 34 children were successfully completed.Among them,25 children underwent direct craniotomy to remove vascular malformations and hematomas;6 children underwent hybrid surgeries;3 children underwent partial embolization of cerebral vascular malformations and then surgical resection.Thirty-one cases(91.2％)of the children underwent total resection of intracranial AVM during the first operation;3 cases(8.8％)underwent near-total or major resection,and 1 case underwent total resection of intracranial AVM during the second operation.Two children died after surgery(both had preoperative SMG points of 3);3 cases developed severe disability(1 had preoperative SMG of 3 points,2 had preoperative SMG of 4),including 2 cases of long-term coma and 1 case of hemiplegia.The GCS score at discharge was 3 to 8 in 2 cases,9 to 12 in 2 cases,and 13 to 15 in 28 cases.All 32 surviving children received clinical follow-up,and the follow-up time was 35.2±10.1 months;as of the last follow-up,there was no residual or recurrence of vascular malformation,26 cases had good outcome,and 6 cases had poor outcome.Compared with preoperative SMG＞3 group,the outcome of children in the preoperative SMG≤3 group was significantly better(the proportions of good outcome were 2/6 and 23/26 respectively,P=0.012).Conclusions Microsurgery is the first choice treatment for hemorrhagic intracranial AVM in children,especially for children with SMG ≤3 points.A reasonable surgical plan should be adopted according to the patient's indications.Preoperative vascular embolization and hybrid surgery can help to completely remove intracranial AVM.
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