Microsurgery for deep cerebralarteriovenous malformations in thalamus, basal ganglia and insula in children

Objective To summarize the experiences of microsurgical removal of deep cerebral arteriovenous malformations (AVMs) in thalamus, basal ganglia and insula in children. Methods A retrospective analysis was conducted for 10 cases of deep cerebral AVMs undergoing microsurgery from June 2015 to June 2018. There were 8 boys and 2 girls with an average age of 7.8 years. The lesions were located in insular lobe (n=4), thalamus (n=3) and basal ganglia (n=3). Eight lesions were <3 cm in diameter, 9 lesions ruptured, 8 lesions were localized, Spetzler-Martin grade III and supplementary grade below IV accounted for 6 and 10 respectively. The outcomes were evaluated by postoperative digital subtraction angiography (DSA) and modified Rankin Scale (mRS) scores at different timepoints. Results The operative approaches were trans-cortical (n=8), lateral fissure (n=1) and corpus callosum (n=1). Among 8 cases of total resection, 1 case of Spetzler-Martin IV underwent emergency microsurgery while another case had emergency ventricular drainage plus second-stage microsurgical lesion removal. Among 4 cases of hemiplegia, one child of Spetzler-Martin IV had a remission after postoperative rehabilitation training. During a follow-up period of 6 months to 3 years, there was no onset of recurrence or rebleeding and 6 of them achieved an excellent outcome. Children scoring <3 via mRS during follow-ups (n=6) were more than preoperation (n=5) and after discharge (n=5). Conclusions Children with deep cerebral AVMs has a high risk of bleeding. For selected small and localized lesions, microsurgical resection offers the advantages of high total resection rate and low rebleeding rate. However, due to high operative difficulties, experienced neurosurgeons are recommended. Key words: Intracranial arteriovenous malformations; Microsurgery; Child