Diagnosis and management of arteriovenous malformations in children.

Arteriovenous malformation (AVM) is the most common cause of spontaneous intraparenchymal hemorrhage in children, excluding hemorrhages of prematurity and early infancy. Because most children diagnosed with an AVM undergo initial treatment emergently, the natural history of AVMs in the pediatric population is not well understood. Most pediatric AVMs do not come to clinical attention unless they hemorrhage. Therefore, their optimal management remains controversial. Children with intracranial AVMs represent a special challenge in that they harbor unacceptable lifelong risks of hemorrhage and potential neurologic deficits. Patients should be evaluated on a case-by-case basis to determine the best multidisciplinary treatment regimen that can be used to preserve neurologic function and eradicate the AVM with the lowest risk of mortality. Successful treatment depends on the location and size of the AVM, its hemodynamic properties, the clinical condition of the patient, and the treatment modality selected. The armamentarium for AVM management has grown with technological advances and now includes microsurgical resection, endovascular embolization, radiosurgery, or any combination of these modalities. Microsurgical resection remains the gold standard for treatment of accessible pediatric AVMs, especially in cases that present with intracranial hemorrhage. Newer modalities, such as embolization and radiosurgery, have provided additional tools to help children with large or deep-seated lesions that would be deemed unresectable with microsurgical techniques alone. Long-term follow-up with repeated diagnostic imaging is important despite complete obliteration of the lesion to rule out the small possibility of AVM recurrence.