Direct surgical treatment of pediatric
intracranial pial arteriovenous fistula
Nara Medical University, Nara, JAPAN
Department of Neurosurgery
YS PARK
Y KOTANI, H YOKOTA, Y Motoyama , H Nakase
Introduction
 Pediatric intracranial pial arteriovenous fistulas
(PIAVFs) are rare vascular lesions and the history and
developmental mechanisms remain unclear.
 Their high flow vascular characteristic and pediatric
populations cause difficulty in the treatment.
 The goal of treatment is to obliterate the AV shunt with
preservation of the normal arterial supply and venous
drainage of the normal brain tissue.
 Here, we report the efficacy and safety of direct surgical
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procedure of PIAVFs based on 7 cases.
Summary of pediatric intracranial pial AVFs
Case
age
sex
bleeding
symptom
feeder
varix
1
1m
F
Yes (ICH)
cons dist, hemiparesis
Lt M2 superior tr.
12mm
2
11m
M
None
convulsion
Lt. pericallosal a.
15mm
3
3y
F
None
macrocrania, convulsion
Lt. M2 superior tr.
23mm
4
10y
M
None
headache
Lt. angular a.
26mm
5
10y
M
Yes (SAH)
headache
Rt. ant temporal a.
19mm
6
14y
M
None
convulsion
Lt. angular a.
26mm
7
16y
F
Yes (ICH)
headache
Rt. splenial a.
20mm
7.7y
3/7
20.2mm
Summary of pediatric intracranial pial AVFs
Case
age
sex
IOM
IONI
Barbiturate TX
Outcome
1
1m
F
None
None
None
Excellent
2
11m
M
MEP
DSA
None
Excellent
3
3y
F
MEP
ICG videography
Done
Excellent
4
10y
M
MEP, SEP
DSA
Done
Excellent
5
10y
M
MEP
ICG videography
Done
Excellent
6
14y
M
MEP, VEP
ICG videography
Done
Excellent
7
16y
F
MEP, VEP
DSA
None
Excellent
4/7
All
7.7y
Results
 In all cases, shunt points were directly identified and
completely disconnected.
 Especially, four cases were conducted barbiturate coma
therapy to prevent postoperative hyperpeufusion events.
 None of seven cases encountered surgical-related
complications. All patients were neurologically excellent
with no deficits at discharge.
 With a mean long-term clinical follow-up of 7.4 years
(3.8–10.7years), there were no signs of recurrences.
Case 3: 3y F
Macrocrania was detected at 6 mo.
Infantile CSDH was developed.
Initial (7 mo) CT
Case 3: 3y F
At the first admission, her patents didn’t want OP.
After ward, developmental delay had been evident.
3 yo MRI T2 WI
Case 3: 3y F
3D CTA
Case 3: 3y F
Case 3: 3y F
Case 3: 3y F
PO 2m 3D CTA
POD3
Post OP 48hrs Barbiturate Tx done
（Under ICP monitoring）
Now, normal development
Discussion
Which is recommended?
Direct surgery
Endovascular
Endovascular
Direct Surgery
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 Why not Endovascular surgery ?
・ High flow vascular lesion
・ Difficulty of staged Tx in young children
・ Risk of radiation exposure
・ High rate of recurrence
・ Migration of embolic material
・ Necessity of well skilled technique
Endovascular
Direct Surgery
 Why Direct surgery ?
・ Exact obliteration of the shunt point of under direct vision
・ Available for complexed shunt points
・ Precise evaluation by ICG videoangiography
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・ Easy access for superficial lesion
Conclusions
 Endovascular treatment of these patients is very
difficult due to the high flow vascular lesions and
distal migrations of emobilization materials have
been frequently reported.
 We recommend the direct disconnection of these
lesions if they are located at the superficial lesions
and we can easily approach them.
 It is obvious that IOM and IONI might be essential
for the direct surgery in PIAVFs.