LoPresti Melissa A, Goethe Eric A, Lam Sandi
Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
Childs Nerv Syst. 2020 Jul;36(7):1445-1452. doi: 10.1007/s00381-020-04501-0. Epub 2020 Jan 13.
Arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children, which can result in elevated intracranial pressure (ICP) and cerebral edema. We sought to explore the role of initial decompressive craniectomy at time of rupture, followed by interval surgical AVM resection, compared to treatment with initial resection, in clinical outcomes and recovery in children.
A retrospective chart review was conducted examining patients age 0-18 with AVM rupture between 2005 and 2018 who underwent resection for ruptured AVM either initially at presentation or underwent initial decompressive craniectomy followed by interval AVM resection. Clinical, radiographic, surgical, and outcome data were examined. Primary outcomes measured included functional status, AVM obliteration rate, AVM recurrence/residual, and re-hemorrhage.
Thirty-six cases were included; 28 (77.8%) underwent initial AVM resection, and 7 (19.4%) underwent initial decompressive craniectomy with interval resection. The mean time between craniectomy and resection was 66.9 days (SD 59.3). Patients undergoing initial decompressive craniectomy with interval resection were younger (mean age 6.1 vs. 9.8 years, p = 0.05) and had a higher mean hematoma volume (52.9 vs. 22.2 mL, p = 0.01), mean midline shift (5.1 vs. 2.1 mm, p = 0.01), and presence of cisternal effacement (p = 0.01). There were no statistically significant associations between surgical strategy and postoperative outcomes, including complications, radiographic outcomes, complete resection, residual, recurrence, and functional outcomes. Those treated by initial craniectomy followed by interval resection were associated with undergoing additional procedures.
Children presenting with AVM rupture who require emergent decompression may safely undergo emergent craniectomy with interval AVM resection and cranioplasty without additional risk of morbidity or mortality. This is reasonable in those with elevated intracranial pressure. This strategy may provide time for initial recovery and allow for natural degradation of the hematoma enhancing the plane for interval AVM resection, perhaps improving outcomes.
动静脉畸形（AVM）是儿童颅内出血的常见原因，可导致颅内压（ICP）升高和脑水肿。我们试图探讨在破裂时进行初次减压性颅骨切除术，随后进行分期手术切除AVM，与初次切除治疗相比，对儿童临床结局和恢复情况的影响。
进行一项回顾性病历审查，研究2005年至2018年间年龄在0至18岁之间因AVM破裂而接受手术治疗的患者，这些患者在初次就诊时即接受破裂AVM切除术，或先进行初次减压性颅骨切除术，随后进行分期AVM切除术。检查临床、影像学、手术和结局数据。测量的主要结局包括功能状态、AVM闭塞率、AVM复发/残留情况以及再出血情况。
共纳入36例病例；28例（77.8%）接受了初次AVM切除术，7例（19.4%）接受了初次减压性颅骨切除术并分期切除。颅骨切除术与切除术之间的平均时间为66.9天（标准差59.3）。接受初次减压性颅骨切除术并分期切除的患者年龄较小（平均年龄6.1岁对9.8岁，p = 0.05），平均血肿体积较大（52.9 mL对22.2 mL，p = 0.01），平均中线移位较大（5.1 mm对2.1 mm，p = 0.01），且存在脑池受压情况（p = 0.01）。手术策略与术后结局之间无统计学显著关联，包括并发症、影像学结局、完全切除、残留、复发和功能结局。先进行颅骨切除术随后分期切除的患者接受了更多额外手术。
因AVM破裂而需要紧急减压的儿童可以安全地接受紧急颅骨切除术并分期进行AVM切除和颅骨成形术，而不会增加发病率或死亡率风险。对于颅内压升高的患者来说，这是合理的。该策略可能为初期恢复提供时间，并使血肿自然吸收，从而改善分期AVM切除的手术视野，也许能改善结局。
