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Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations

Philippe G. Meyer , MD^*, Gilles A. Orliaguet , MD ^*, Michel Zerah, MD, Brigitte Charron, MD^*, Marie-Madeleine Jarreau, MD^*, Francis Brunelle, MD, Anne Laurent-Vannier, MD and Pierre A. Carli , MD^*

^* From the Department of Paediatric Anaesthesia,
Paediatric Neurosurgery,
Paediatric Radiology,
Assistance Publique-Hopitaux de Paris-Université Paris V, Centre Hospitalier Universitaire Necker-Enfants Malades, Paris, and Department of Paediatric Neurological Rehabilitation, Hopital National de Saint Maurice, Saint Maurice, France.

Address correspondence to: Dr. Philippe-Gabriel Meyer, Assistance Publique-Hopitaux de Paris, Centre Hospitalier Universitaire Necker-Enfants Malades, Département d'Anesthésie-Réanimation, 149 rue de Sèvres, 75015 Paris, France. Phone: 33-1-44-49-41-83; Fax: 33-1-44-49-41-70; E-mail: philippe.meyer{at}nck.ap-hop-paris.fr

Purpose: To assess the impact of emergency management on mortality and morbidity of acute rupture of cerebral arteriovenous malformations resulting in deep coma in children, and the factors predicting outcome.

Methods: Retrospective chart review of 20 children with a Glasgow Coma Scale # 8 with acute hemorrhagic stroke from a cerebral arteriovenous malformation rupture was conducted. Protocol included: early resuscitation with tracheal intubation and ventilation after induction of anesthesia with sufentanil, and benzodiazepine, and mannitol 20% or hypertonic saline 7.5% infusion for life-threatening brain herniation. Radiological exploration was limited to contrast-enhanced CT scan preceding immediate surgical decompression. Postoperatively, children were deeply sedated and intracranial pressure monitoring allowed titration with osmotherapy , vasopressors, hyperventilation or barbiturate coma to control cerebral perfusion pressure. Analysis used stratification of the type of hemorrhage (supra or infra tentorial), location (intraparenchymal and subarachnoid, intraparenchymal and intraventricular or intraventricular alone) and relationship between presentation, evolution with resuscitation, type of cerebral lesion, and outcome.

Results: Patients had a severe initial presentation (median Glasgow Coma Scale five), eight had unilateral and eight bilateral third nerve palsy. Compressive hematoma in supratentorial localisation represented 75% of the cases. Global mortality was 40%. Persistence of mydriasis after resuscitation increased mortality to 75%. Massive intraventricular flooding was associated with increased mortality. Good functional outcome was achieved in survivors.

Conclusion: Acute rupture of an AVM can result in rapidly progressing coma. Emergency management with early resuscitation, minimal radiological exploration before rapid surgical decompression results in a mortality rate of 40%, but a good functional outcome can be expected in the survivors.

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