Pediatric emergency medicine trisk 4008 4008

certainly a well-established role for adjunctive endovascular embolization
of some AVMs. Clearly, there are specific situations, such as small deep
AVMs in eloquent brain structures, where microsurgery should not be used
as the primary treatment modality; stereotactic radiosurgery and
occasionally embolization (when there is reasonable expectation of
complete obliteration by embolization) are the preferred treatment options
in these cases. We also make a case for observation in patients with large
AVMs in or near critical areas of the brain that are not ideal for surgical
resection or radiosurgery. Here, the pursuit of treatment may actually be
more harmful to the patient than the natural history of the AVM.
Indications for Surgical Resection. There are several clear indications for
microsurgical resection of AVMs. AVMs with Spetzler–Martin grades I to
III on the convexity should generally be resected. The Spetzler–Martin
grading system takes into account three factors that greatly affect the
surgical resectability of the AVM: size (<3 cm, 1 point; 3 to 6 cm, 2 points;
>6 cm, 3 points), location (noneloquent cortex, 0 points; eloquent cortex, 1
point), and venous drainage (superficial only, 0 points; deep, 1 point).
Patients with AVMs that present with major hemorrhage, progressive
neurologic deterioration, inadequately controlled seizures, intractable
headache, or venous restrictive disease should be strongly considered for
surgical intervention, including resection, hematoma evacuation, or acute
spinal fluid diversion.
Cerebellar and pial brainstem AVMs should also be given strong
consideration for surgical resection to prevent the higher risk of bleeding as
compared to supratentorial AVMs. Some basal ganglia and thalamic AVMs
should be surgically resected, as they carry a considerably higher annual
bleed rate of 11.4%; in addition, morbidity and mortality with each bleed in
these locations reach 7.1% and 42.9%, respectively (again, in contrast to the
overall mortality rate of AVM hemorrhage of 10%).
Hence, one may justify a more aggressive approach for surgical treatment
in younger patients as their cumulative risk of hemorrhage is so high. In

addition, neurologic deficit caused at a young age is generally better
tolerated and has a greater chance of recovery.

ACUTE HYDROCEPHALUS