Choices in the 1990s for the management of pediatric cerebral arteriovenous malformations.

A retrospective 45-year analysis of the management of 160 children with intracranial arteriovenous malformations at The Hospital for Sick Children, Toronto, reveals substantially improving outcomes which relate to more efficient diagnoses and treatments. 80% of children will declare their malformation by means of spontaneous intracranial hemorrhage. For those children who present with hemorrhage or epilepsy, 80% will require an operation. The overall mortality rate has declined to 12% since 1975 and that for the cerebellar lesions from 67 to 42%. 53% of the patients operated upon will be neurologically normal. Endovascular embolization of a child's AVM is a customized, partial solution for a limited number of children. Stereotactic radiosurgery will be used increasingly to obliterate those small lesions in children which are unassociated with hemorrhage or are the residua of an operation. As many as 10% of children (15/160) with diagnosed AVMs cannot be helped with operative or other interventional therapies. The recognition of the pediatric stroke syndromes, the early triage and diagnosis of a child's cerebral hemorrhage, the operative and anaesthetic technologies and the adjunct therapies - choices of the nineties - have resulted in a 66% decline in the overall mortality from this vascular lesion as well as greater assuredness that for most the lesion can be permanently obliterated.