Multimodal management of pediatric brain arteriovenous malformations: single-center experience from a retrospective observational study

BACKGROUND: Intracranial arteriovenous malformations (AVMs) are a major cause of intracranial hemorrhage (ICH) in children, often leading to significant neurological deficits or mortality. The primary aim of this study was to analyze the management strategies and long-term outcomes of pediatric AVMs treated at Santobono-Pausilipon Children's Hospital over the past 15 years with a particular focus on hemorrhagic presentation. METHODS: A retrospective review was conducted on pediatric patients (0-18 years) diagnosed with intracranial AVMs between July 2008 and December 2024. Data on demographics, clinical presentation, imaging findings, Spetzler-Martin and Supplemented Spetzler-Martin grading, treatment modalities, complications, and outcomes were collected. Treatment approaches included microsurgical resection, endovascular embolization, stereotactic radiosurgery (SRS), and multimodal management were evaluated. RESULTS: A total of 48 pediatric AVM cases were identified (24 males, 24 females; mean age: 8.8 years). The majority (N.=41, 85.4%)) presented with intracranial hemorrhage. Treatment strategies included microsurgical resection (17 cases), embolization (6 cases), SRS (9 cases), and multimodal therapy (14 cases). Mean follow-up was 5 years. Residual AVMs were detected in 13% of cases, with three rebleeding events. The postoperative modified Rankin Scale (mRS) showed favorable outcomes (mRS 0-2) in 37 patients. One patient died due to major hemorrhage. CONCLUSIONS: Pediatric AVMs exhibit diverse clinical presentations and require individualized management strategies. While surgical resection remains the most definitive treatment, multimodal approaches may be necessary for high-grade or deep-seated AVMs. Long-term follow-up is crucial due to the risk of AVM recurrence and rebleeding. Advancements in molecular and genetic research may further refine therapeutic strategies for pediatric AVMs in the future.