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Joseph J, Raju KP, Jonathan GE, B R, Ganesh S, S P, Godson HF. Hypofractionated stereotactic radiotherapy in Spetzler Martin grades 4 and 5 arteriovenous malformations in the pediatric population: Is it a viable alternative? Childs Nerv Syst 2024; 40:1185-1192. [PMID: 38071636 DOI: 10.1007/s00381-023-06244-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/28/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To analyze the outcomes of hypofractionated stereotactic radiotherapy (HFSRT) for Spetzler Martin grades 4 and 5 arteriovenous malformations (AVMs) in a pediatric population. METHODS Fourteen patients with Spetzler Martin (SM) grades IV and V large AVMs who underwent HFSRT between January 2013 and July 2019 were retrospectively reviewed. All patients received HFSRT at a dose of 30-36 Gy in 5 to 6 fractions. They were followed up annually with clinical and imaging assessments to evaluate obliteration rates. RESULTS The median age at presentation was 15 years (range 8-21 years). Ten (71%) were SM grade 4 AVMs and the rest were SM grade 5 AVMs. The majority presented with headache (8 [57%]), and 3 (21%) presented with bleeding. The median nidus volume was 39.4 cc (IQR, 31.4-52.4). Two (14%) patients had infratentorial AVMs. All of them had deep venous drainage. The median clinical follow-up duration was 75 months (range 31-107 months). There was complete obliteration of the nidus in 3 (21%) patients with a median time to obliteration of 39 months. HFSRT resulted in a reduction of the AVM volume to 12 cc or less in nearly 70% of patients. None of the patients experienced re-bleeding. 79% reported an improvement in their symptoms. CONCLUSION HFSRT is a highly effective treatment for high-grade AVMs in children, which can result in either complete elimination or significant reduction of the nidus volume or make it suitable for additional treatment, such as single-session stereotactic radiosurgery (SRS).
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Affiliation(s)
- Jeena Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Krishna Prabhu Raju
- Department of Neurological Sciences, Christian Medical College, Vellore, India.
| | | | - Rajesh B
- Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Swaminathan Ganesh
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Patricia S
- Department of Radiation Oncology, Christian Medical College, Vellore, India
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Baranoski JF, Koester SW, Catapano JS, Garcia JH, Pacult MA, Hoglund BK, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Rutledge C, Srinivasan VM, Graffeo CS, Ducruet AF, Albuquerque FC, Lawton MT. Early Treatment of Ruptured Cerebral Arteriovenous Malformations: Analysis of Neurological Outcomes and Health Care Costs. Neurosurgery 2024; 94:212-216. [PMID: 37665224 DOI: 10.1227/neu.0000000000002641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The timing of surgical resection is controversial when managing ruptured arteriovenous malformations (AVMs) and varies considerably among centers. OBJECTIVE To retrospectively analyze clinical outcomes and hospital costs associated with delayed treatment in a ruptured cerebral AVM patient cohort. METHODS Patients undergoing surgical treatment for a ruptured cerebral AVM (January 1, 2015-December 31, 2020) were retrospectively analyzed. Patients who underwent emergent treatment of a ruptured AVM because of acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgical intervention relative to AVM rupture into early (postbleed days 1-20) and delayed (postbleed days 21-180) treatment cohorts. RESULTS Eighty-seven patients were identified. The early treatment cohort comprised 75 (86%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 5 (5) days in the early cohort and 73 (60) days in the delayed cohort ( P < .001). The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation ( P ≥ .15). Follow-up neurological status was equivalent between the cohorts ( P = .65). The associated mean health care costs were higher in the delayed treatment cohort ($241 597 [$99 363]) than in the early treatment cohort ($133 989 [$110 947]) ( P = .02). After adjustment for length of stay, each day of delayed treatment increased cost by a mean of $2465 (95% CI = $967-$3964, P = .002). CONCLUSION Early treatment of ruptured AVMs was associated with significantly lower health care costs than delayed treatment, but surgical and neurological outcomes were equivalent.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Chowdhury SS, See AP, Eriksson LP, Boulouis G, Lehman LL, Hararr DB, Zabih V, Dlamini N, Fox C, Waak M. Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review. Semin Pediatr Neurol 2022; 43:101001. [PMID: 36344021 DOI: 10.1016/j.spen.2022.101001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma >2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).
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Affiliation(s)
| | | | | | | | | | | | - Veda Zabih
- The Hospital for Sick Children, Toronto, Canada
| | | | | | - Michaela Waak
- The University of Queensland, Australia; Children's Health Queensland Hospital, Brisbane, Australia
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Oomori M, Ito S, Higuchi K. Fatal ruptured occult arteriovenous malformation in a young adult: An autopsy case report. Surg Neurol Int 2022; 13:284. [PMID: 35855123 PMCID: PMC9282792 DOI: 10.25259/sni_427_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/13/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Brain arteriovenous malformations (AVMs) are congenital developmental disorders with unclear causative factors and pathogenic mechanisms. Various epigenetic factors may influence the development and rupture of AVMs. Ruptured AVMs may lead to poor outcomes. Therefore, the risk factors of AVM rupture and treatment strategies for unruptured AVMs should be explored. Herein, we report a case of a fatal ruptured AVM diagnosed by radiological and autopsy findings and review the literature regarding AVM treatment.
Case Description:
A 46-year-old man was brought to the hospital with sudden loss of consciousness while sitting on the edge of the bathtub. On examination, he was unconscious with poor breathing efforts. He was intubated and a brain CT scan was performed, which showed an intracerebral hemorrhage (ICH) adjacent to the right trigone with massive intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Contrast-enhanced CT scan showed abnormal vessels adjacent to the hematoma. He was diagnosed with ICH associated with IVH and SAH caused by a ruptured abnormal vascular lesion. He underwent external ventricular drainage to control the intracranial pressure. He remained unconscious and died 16 h after hospital admission. Autopsy was performed to identify the cause of ICH. Pathological sections showed a mass of blood vessels, measuring 20 × 10 × 10 mm in size, within the hematoma with a single drainer connecting to the transverse sinus. These blood vessels had variable size, shape, and wall thickness on microscopy. Some vessels had abnormal thickened walls with discontinuous elastic fibers. Based on the radiological and autopsy findings, an ICH secondary to SpetzlerMartin Grade I AVM was confirmed.
Conclusion:
If the cause of ICH cannot be determined during a patient’s life, autopsy may be performed to determine the pathophysiology of occult vascular lesions, including AVMs. Patients with AVMs may have moderate or no symptoms before and after rupture. Because deep AVMs fed by posterior circulation have high risk of bleeding, surgical intervention should be considered for these patients to prevent a poor outcome. Low-grade and paraventricular AVMs in a young adult may be successfully treated with multimodal surgery.
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Affiliation(s)
- Makiko Oomori
- Department of Residency, Japanese Red Cross Nagahama Hospital, Nagahama, Nagahama, Japan
| | - Sayaka Ito
- Department of Neurosurgery, Kohka Public Hospital, Kohka, Nagahama, Japan
| | - Kazushi Higuchi
- Department of Neurosurgery, Japanese Red Cross Nagahama Hospital, Nagahama, Japan
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2021; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Stricker S, Boulouis G, Benichi S, Bourgeois M, Gariel F, Garzelli L, Hak JF, Alias Q, Kerleroux B, Beccaria K, Chivet A, de Saint Denis T, James S, Paternoster G, Zerah M, Kossorotoff M, Boddaert N, Brunelle F, Meyer P, Puget S, Naggara O, Blauwblomme T. Acute surgical management of children with ruptured brain arteriovenous malformation. J Neurosurg Pediatr 2021; 27:437-445. [PMID: 33482644 DOI: 10.3171/2020.8.peds20479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM. METHODS This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury. RESULTS A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently. CONCLUSIONS HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.
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Affiliation(s)
| | - Grégoire Boulouis
- 2Université de Paris.,3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Florent Gariel
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Lorenzo Garzelli
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Basile Kerleroux
- 2Université de Paris.,3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | | | | | | | | | | | - Nathalie Boddaert
- 1APHP, Necker Hospital.,2Université de Paris.,4INSERM U1163, Imagine Institute, Paris, France
| | | | | | | | - Olivier Naggara
- 1APHP, Necker Hospital.,2Université de Paris.,3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Thomas Blauwblomme
- 1APHP, Necker Hospital.,2Université de Paris.,4INSERM U1163, Imagine Institute, Paris, France
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LoPresti MA, Goethe EA, Lam S. Surgical strategies for management of pediatric arteriovenous malformation rupture: the role of initial decompressive craniectomy. Childs Nerv Syst 2020; 36:1445-1452. [PMID: 31932976 DOI: 10.1007/s00381-020-04501-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/02/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
- Division of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sandi Lam
- Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Boulouis G, Blauwblomme T, Hak JF, Benichi S, Kirton A, Meyer P, Chevignard M, Tournier-Lasserve E, Mackay MT, Chabrier S, Cordonnier C, Kossorotoff M, Naggara O. Nontraumatic Pediatric Intracerebral Hemorrhage. Stroke 2019; 50:3654-3661. [DOI: 10.1161/strokeaha.119.025783] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Gregoire Boulouis
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Jean François Hak
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
- Neuroimaging Department, CHRU La Timone, Marseille, France (J.F.H.)
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Institut Imagine, INSERM UMR 1163, NEM (T.B., S.B.)
| | - Adam Kirton
- Departments of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, AB, Canada (A.K.)
- Pediatric Neuro ICU (A.K.)
| | | | - Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint-Maurice Hospitals (M.C.)
| | - Elisabeth Tournier-Lasserve
- Genetics of Neurovascular disorders, AP-HP, Hôpital Lariboisière and Université de Paris, NeuroDiderot, Inserm, F-75010 (E.T.-L.)
| | - Mark T. Mackay
- Neurology Department, Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, and Department of Paediatrics, University of Melbourne, Australia (M.T.M.)
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Center for Pediatic Stroke, F-42055 Saint-Étienne, France (S.C.)
| | - Charlotte Cordonnier
- Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Neurology Department, France (C.C.)
| | - Manoëlle Kossorotoff
- Department of Pediatric Neurology, French Center for Pediatic Stroke, NEM (M.K.)
| | - Olivier Naggara
- From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.)
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9
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Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31:533-541. [PMID: 31041848 DOI: 10.1111/1742-6723.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/30/2022]
Abstract
Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
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Affiliation(s)
- Pieter F Fouche
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, South Africa
| | | | - Malcolm Boyle
- School of Medicine, Griffith University, Griffith, Queensland, Australia
| | - Stephen Bernard
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
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Walkden JS, Zador Z, Herwadkar A, Kamaly-Asl ID. Use of intraoperative Doppler ultrasound with neuronavigation to guide arteriovenous malformation resection: a pediatric case series. J Neurosurg Pediatr 2015; 15:291-300. [PMID: 25525933 DOI: 10.3171/2014.10.peds14249] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Over the last 20 years, several intraoperative adjuncts, including ultrasonography, neuronavigation, and angiography, have been said to aid the intraoperative localization and resection of cerebral arteriovenous malformations (AVMs). The authors assessed the value of intraoperative Doppler ultrasonography in conjunction with neuronavigation during surgery for cerebral AVMs in the pediatric population. METHODS The authors reviewed all cranial AVM resections performed by a single surgeon at their institution in the period from 2007 to 2013 and here describe their experience and results in a series of 20 consecutive AVM resections in 19 pediatric patients. Intraoperative Doppler ultrasonography had been used in conjunction with preoperative CT or neuronavigational MRI. Preoperative and postoperative clinical findings, patient age, and Spetzler-Martin AVM grade were identified in all patients. RESULTS All patients, whose ages ranged from 2 to 16 years, underwent craniotomy and excision of an AVM, which was supratentorial in 18 cases and infratentorial in 2. Patients in 11 cases underwent preoperative embolization, and all other patients underwent cerebral angiography prior to surgery, except for 2 patients who were urgently surgically treated because of low Glasgow Coma Scale scores and associated hematoma. Spetzler-Martin Grades I (3 cases), II (6), III (7), and IV (4) AVMs were represented in this series. Intraoperative Doppler ultrasound provided high-quality images in all cases and demonstrated the location, size, and flow characteristics of the AVM and any associated hematoma. Delayed postoperative cerebral angiography demonstrated successful AVM resection in all cases. An assessment of clinical outcomes revealed no new long-term neurological deficits at 3 months postoperatively. CONCLUSIONS Intraoperative Doppler ultrasonography is a reliable and useful tool for intraoperative localization and guidance for AVM resection in the pediatric population. When used in conjunction with neuronavigation equipment and modern microscopes, this technique has shown a very high complete resection rate with extremely low associated morbidity.
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Affiliation(s)
- James S Walkden
- Departments of Neurosurgery and Neuroradiology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Blamek S, Larysz D, Miszczyk L. Stereotactic linac radiosurgery and hypofractionated stereotactic radiotherapy for pediatric arteriovenous malformations of the brain: experiences of a single institution. Childs Nerv Syst 2013; 29:651-6. [PMID: 23224360 PMCID: PMC3594818 DOI: 10.1007/s00381-012-1983-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 11/15/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of our study was to evaluate treatment results and toxicity of stereotactic irradiation for arteriovenous malformations (AVMs) in children. METHODS A group of ten consecutive children (four boys and six girls) irradiated between 2002 and 2010 at our institution was included into the study. The mean age at the time of treatment was 15.4 and ranged between 8 and 18 years. There were two Spetzler-Martin grade IV, four grade III, and four grade II lesions. Mean AVM volume was 13.2 cm(3) and varied from 0.6 to 36.8 cm(3). In five patients, the planned dose of 16-20 Gy was delivered in single fraction, in five the total dose of 16-24 Gy was delivered in two to three fractions. One patient was reirradiated with a dose of 15 Gy, 7 years after the initial treatment. RESULTS The median follow-up was 38.5 months. The treatment resulted in total obliteration in eight patients and partial in one. The median time to obliteration was 22 months; actuarial total obliteration rates were 20, 54, 54, and 83 % after 1, 2, 3, and 4 years of follow-up, respectively. No patient bled after the treatment. In one patient, new epileptic seizures developed after the treatment; in magnetic resonance imaging, focal necrosis was revealed. In five patients, asymptomatic imaging abnormalities were seen during follow-up. CONCLUSIONS Stereotactic radiotherapy appears to be an effective method of treatment for pediatric AVMs, the patients however require meticulous follow-up because of relative high incidence of radiation-induced imaging abnormalities.
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Affiliation(s)
- Sławomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland.
| | - Dawid Larysz
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland ,Department of Neurosurgery, Silesian University of Medicine, ul. Medyków 14, 40-752 Katowice, Poland
| | - Leszek Miszczyk
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland
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[Experts' recommendations: stroke management in the intensive care unit. Pediatric specificities (excluding neonates)]. Rev Neurol (Paris) 2012; 168:527-32. [PMID: 22579503 DOI: 10.1016/j.neurol.2010.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 10/20/2010] [Accepted: 11/22/2010] [Indexed: 11/21/2022]
Abstract
Stroke in children is not rare. Although there are no randomized trials on childhood stroke, except in sickle cell disease patients, several international guidelines have described quality criteria for stroke management in children. Age-adapted management is required, involving collaboration with a pediatric neurologist and hospitalization in a pediatric intensive care or continuous care unit. All symptomatic treatments used in adults can be recommended in children, including homeostasis assessment and maintenance or blood exchange in sickle cell disease patients. Specific treatments such as thrombolysis or mechanical thrombectomy are not recommended in children, except in the framework of clinical trials, but can be beneficial in adolescents. Multidisciplinary decision-making should be the rule in such situations. Adolescents may be managed in adult stroke units. Indications for surgery in children are adapted from adult guidelines. Appropriate management of cerebral venous thrombosis in children is similar to that in adults. The best management possible can be achieved through a multidisciplinary dialogue between the pediatric neurologist and the adult intensivist or neurologist.
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Rahme R, Weil AG, Bojanowski MW. Outcome of severe arteriovenous malformation-related intracranial hemorrhage: the importance of cisternal subarachnoid hemorrhage and early seizures. Acta Neurochir (Wien) 2011; 153:897-903. [PMID: 21234617 DOI: 10.1007/s00701-010-0927-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although arteriovenous malformations (AVM)-related intracranial hemorrhage (ICH) is infrequently devastating, there is a subgroup of patients that present comatose requiring immediate surgical treatment. We sought to determine the outcome and prognostic factors in those patients with severe AVM-ICH. METHODS Between 2003 and 2009, medical records of 16 consecutive patients presented with severe AVM-ICH were retrospectively reviewed. Outcome was determined using 30-day survival and Glasgow outcome scale and modified Rankin scale scores at last follow-up. RESULTS There were seven males and nine females with a mean age of 32 years (range 6-66). All had Glasgow coma score 8 or less and most exhibited motor posturing and/or dilated pupils. Fifteen patients had intraprenchymal, ten had intraventricular, and four had subarachnoid hemorrhage (SAH). Twelve patients underwent hematoma evacuation with concomitant decompressive craniectomy in 11 and external ventricular drainage (EVD) in six. EVD was the only treatment offered to four patients. AVM excision was not routinely attempted in the acute phase. Three patients died from extensive bihemispheric infarction and refractory intracranial pressure. All 13 survivors improved neurologically and 12 had an acceptable functional outcome (modified Rankin scale ≤ 4) after a mean follow-up of 10 months (range 1-49). Among all clinical, radiological, and operative variables, only cisternal SAH (P = 0.007) and early seizures (P = 0.018) were significantly associated with death. CONCLUSION Despite their poor initial clinical condition, most survivors of severe AVM-ICH achieve an acceptable functional outcome. Therefore, patients with severe AVM-ICH, particularly those without aneurysmal-like SAH, should be managed aggressively given their remarkable potential for neurological recovery.
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Mukerji N, Cahill J, Tzerakis N, Nath FP, Dervin JE. Venous anastomotic circle, multiple varices and oculomotor palsy--a rare coincidence. Acta Neurochir (Wien) 2010; 152:2205-9. [PMID: 20927560 DOI: 10.1007/s00701-010-0819-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/23/2010] [Indexed: 11/28/2022]
Abstract
Oculomotor nerve palsy due to a venous varix arising from flow anomalies caused by a dural arteriovenous fistula (AVF) is a rare phenomenon. We report a case of surgical third nerve palsy with a rare underlying AVF as the cause and discuss in detail the patho-anatomy and its significance. A tentorial dural AVF mimicking the arterial circle was found with multiple varix formation causing compressive oculomotor palsy. This was treated successfully with Onyx™ injection with a satisfactory angiographic result and complete resolution of symptoms.
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Affiliation(s)
- Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK.
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Catré D, Viana JS, Cabrita AM, Oliveira M, Felizes A, Lopes MF. Hydroxyethyl starch 130/0.4 attenuates early hepatic damage in ischemia/reperfusion injury. Can J Anaesth 2010; 57:439-45. [PMID: 20151340 DOI: 10.1007/s12630-010-9282-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 02/01/2010] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Ischemia/reperfusion injury (IRI) remains a clinical challenge. We tested the hypothesis that fluid therapy using hydroxyethyl starch (HES) 130/0.4 during the early phase of IRI in rat liver decreases markers of hepatic injury. METHODS We induced liver IRI in three groups of rats anesthetized with ketamine and chlorpromazine by means of 60 min of segmental hepatic ischemia followed by 120 min of reperfusion. At the onset of reperfusion, Group 1 (IRI + HES; n = 12) was given 13 mL.kg(-1) of HES; Group 2 (IRI + HS; n = 12) received the same volume of 7.5% saline (HS), and Group 3 (IRI-only; n = 12) received no fluid. Three other groups of 12 animals each were sham-operated and received the same fluid as the test groups. We euthanized the animals after three hours, drew blood for alanine aminotransferase (ALT) quantification, and took ischemic liver samples for histomorphological study. RESULTS Serum ALT activity was greater in all of the IRI groups than in the sham-operated animals. The ALT activity was 1,081 +/- 575 IU.L(-1) in IRI + HES Group 1; 2,363 +/- 1,839 IU.L(-1) in IRI + HS Group 2; and 2,866 +/- 2,491 IU.L(-1) in IRI-only Group 3. There was a statistically significant difference between the IRI + HES and the IRI-only groups (P = 0.001), but not between the IRI + HS and the IRI-only groups (P > 0.05). Likewise, histological scores were greater in all IRI groups compared with the sham-operated animals. Scores were higher in the IRI-only group (median 3.5) than in the groups receiving fluid (IRI + HES median 2; IRI + HS median 3). The difference between IRI + HES and IRI-only was statistically significant (P = 0.008) but not so between IRI + HS and IRI-only (P > 0.05). CONCLUSIONS Giving HES 130/0.4 attenuates rat liver IRI compared with no fluid, while giving HS does not. This suggests a role for HES in hepatoprotection associated with liver IRI.
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Affiliation(s)
- Dora Catré
- School of Medicine of the University of Coimbra, Coimbra, Portugal,
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Wong ST, Fong D. Ruptured brain arteriovenous malformations in children: correlation of clinical outcome with admission parameters. Pediatr Neurosurg 2010; 46:417-26. [PMID: 21540618 DOI: 10.1159/000324910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
Abstract
AIMS To gain a better understanding of how clinical outcome in children with ruptured brain arteriovenous malformations (bAVMs) correlates with clinical and imaging parameters on admission. METHODS The authors retrospectively reviewed patients with bAVMs, aged 18 or below, managed at their hospital between January 1992 and December 2008. Clinical outcome was assessed using the modified Rankin Scale (mRS). Patients with ruptured bAVMs were analyzed; their clinical parameters and computerized tomography findings on admission were recorded. Clinical outcome was then evaluated against admission scores using the Glasgow Coma Scale (GCS), the World Federation of Neurosurgical Societies Grading System of Subarachnoid Hemorrhage (WFNS-SAH), the Spetzler-Martin grade, the intracerebral hemorrhage score and 2 other independent parameters, namely pupillary response and significant focal neurological injuries. Spearman's correlation coefficient, linear regression analysis and multivariate logistic regression analysis were used for data analysis. RESULTS 40 pediatric patients with bAVMs were found and 32 of them presented with hemorrhage (80%). In the 32 children with ruptured bAVMS, follow-up ranged between 7 and 204 months (median 100.5 months). The complete excision/obliteration rate as confirmed by digital subtraction angiography was 73.3%. The mRS scores at the last follow-up were: grades 0-II in 87.5%; grades IV-V in 6.25%, and grade VI in 6.25%. The Spetzler-Martin grade, the intracerebral hemorrhage score, the WFNS-SAH grade, the GCS scores, and a combined scoring scale consisting of the GCS, pupillary response and significant focal neurological injuries correlated significantly with clinical outcome 6 months after hemorrhage. However, on the scatter diagrams, it appeared that only the combined scoring scale might be valid for clinical practice. Multivariate logistic regression analysis showed that the combined scoring scale was a statistically significant independent predictor of clinical outcome 6 months after hemorrhage. CONCLUSION In this series of pediatric patients with ruptured bAVMs, although various grading scales correlated significantly with clinical outcome 6 months after hemorrhage, only the combined scoring scale might have the potential to be applied to predict clinical outcome in these children.
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Affiliation(s)
- Sui-To Wong
- Department of Neurosurgery, Tuen Mun Hospital, Tuen Mun, Hong Kong, SAR, China.
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Pavesi G, Rustemi O, Berlucchi S, Frigo AC, Gerunda V, Scienza R. Acute surgical removal of low-grade (Spetzler-Martin I-II) bleeding arteriovenous malformations. ACTA ACUST UNITED AC 2009; 72:662-7. [DOI: 10.1016/j.surneu.2009.03.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW The capabilities of interventional radiology are developing faster than perhaps any other branch of medicine. Coupled with and fuelled by parallel advances in computer technology, medical physics and developments in endovascular catheter technology, interventional radiologists are innovating not only replacements for open surgeries, but entirely new therapies as well. This has, however, provided a range of new potential complications for the patient and, in contrast to other areas, presents risks for the anesthesiologist as well. RECENT FINDINGS The techniques involved in interventional radiology have found applications throughout not only medicine but surgery in particular. Here there has been a medicalization of surgical procedures. CT scanning has evolved to the extent that it is now possible to utilize multislice CT scanners, ones with multiple, flat panel digital detectors, to provide real time CT fluoroscopy. Similarly this technology has facilitated the construction of hybrid iMR/X-ray systems, thus enabling dual modality imaging without moving the patient. Another facet of the new breed of iMR systems is their integration in real time with computerized, frameless stereotactic navigation systems. This has enabled the radiological image to keep pace with the changes in anatomy consequent to anesthetic and surgical manipulations. SUMMARY In the light of these new developments in interventional radiology there is much research to be done. Further developments in imaging and computer processing technology will doubtless make possible the real time integration of anatomical image with metabolic state and functional anatomy. The impact of the hazards of these new techniques on the safety of anesthesia has, however, been the subject of virtually no research. A particularly needy area will be the ergonomics of the delivery of anesthesia care in these new environments.
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Meyer P, Orliaguet G, Blanot S, Cuttaree H, Jarreau MM, Charron B, Carli P. [Anesthesia-resuscitation for intracranial expansive processes in children]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21:90-102. [PMID: 11915482 DOI: 10.1016/s0750-7658(01)00517-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The most frequent space-occupying cerebral lesions in children are brain tumors, mostly posterior fossa tumors and haematoma resulting from arteriovenous malformation rupture. They result in intracranial hypertension, directly or by compression of the cerebrospinal fluid pathway resulting in hydrocephalus. Their localization and compressive effects are responsible for specific neurological deficits and general problems. Posterior fossa lesions carry a high risk of obstructive hydrocephalus, cranial nerves palsy and brain stem compression, pituitary and chiasmatic tumors a risk of blindness, pituitary deficiency and diabetes insipidus, and cortical tumors a risk of motor deficit and epilepsy. All these parameters must be analyzed before choosing anaesthetic protocols, and surgical techniques. In the presence of life-threatening intracranial hypertension, emergency anaesthetic induction, tracheal intubation and ventilation are life-saving. The specific treatment consists in either hydrocephalus derivation, initial medical treatment with osmotherapy, or rarely surgical removal. In other situations, surgical process requires a highly deep, stable anaesthesia with perfect control of cerebral haemodynamics. Surgical positioning is complex for these long lasting procedures and carries specific risks. The most common is venous air embolism in the sitting position that must be prevented by the use of specific measures. In the postoperative period, the risk of neurological and general complications commands close surveillance, fast track extubation must be adapted on an individual basis.
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Affiliation(s)
- P Meyer
- Département d'anesthésie-réanimation chirurgicale, secteur pédiatrique, CHU Necker-Enfants Malades, 149, rue de Sèvres 75015 Paris, France.
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Affiliation(s)
- F J Kirkham
- Neurosciences Unit, Institute of Child Health (University College London), 30 Guilford Street, London WC1N 1EH.
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Abstract
Neuroemergencies are life-threatening situations in which, whatever the cause, common pathologic phenomena result in secondary brain lesions. The goal of critical care management is to stop these self-aggravating processes as soon as possible. Initial resuscitation is devoted to control of the airway and hemodynamic and hydroelectrolytic stabilization. With mass lesions, minimal computed tomographic exploration immediately precedes surgical decompression. Further critical care adapted to the child's needs requires multimodal monitoring. Normoventilation, deep sedation, osmotherapy with mannitol or hypertonic saline solutions, and optimization of mean arterial pressure are the basis of management. A purely pressure-driven approach aimed at controlling cerebral perfusion pressure could be potentially harmful, and associated measurement of blood flow velocity with transcranial Doppler and jugular bulb oxygen saturation monitoring allows an approach to cerebral blood flow and metabolism. Outcome can be improved in dangerous situations such as severe brain injuries, cerebral arteriovenous malformation rupture, status epilepticus, and acute hydrocephalus, provided that emergency management could be applied efficiently.
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Affiliation(s)
- P G Meyer
- Pediatric Neurointensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Necker Enfants Malades et Université V, Paris, France.
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