Intracranial Haemorrhage in Children : Surgical Experience Paediatric Vascular Diseases

P. Lasjaunias AVM

2 completely different series Bicêtre. P.Lasjaunias 102 PAVMs Secondary care Diagnosis / Bleeding = 47% Necker 103 PAVMs Primary care 98 Haemorrhage 4 Epilepsy 1 Exophtalmia Humphreys.Toronto children

Necker 2002 * * 16 millions inhabitants 3.5 millions children 16 millions inhabitants 3.5 millions children 1/ children /year

Necker PAVMs SR : 1.2 : 1 (M:F) Mean age : 9.7 (±3.3) Median age : 9.5 (1-15) Bleeding : 98 (97%) GCS ≤ 8 = 43 Deaths = 17 (17%, 40%) Diagnosis/Haemorrhage 47% (Lasjaunias 1992) 79% (Humphreys1996) 55-77% (Celli 1984) GCS ≤8 37% (Humphreys1996) 23-31% (Celli 1984) Mortality 21% (Humphreys1996) 7-13% (Celli 1984)

Haemorrages in cerebral AVM in children and adults Children %Adults % Frequency Mortality Coma Immediate Morbidity

Symptoms N% Headaches2865% Vomiting1330% Seizures25% Acute Neurological Deficit1125%

Primary care (1) SAMU (paramedics) NTI, Ventilation, Sedation Emergency Room Central Line Osmotherapy : Manitol 20% (5mg/kg) HyperT. Saline (3ml/kg) Plasmatic osmolarity : mOsm/l

Initial GCS GCSN% GCS 3410% GCS 41535% GCS 5920% GCS 625% GCS 7615% GCS 8615%

Initial Care (2) RadiologyN CT15 CT w Contrast27 MR1 Angiogram9

Location N% SAH410% Frontal25% Occipital25% Temporo-parietal1330% Deep seated1125% Posterior fossa1125%

Groupe A N= 17 (40%) Groupe B N= 22 (50%) Groupe C N= 4 (10%)

Contrast ?

Emergency MR

Initial Treatment TreatmentN% EVD % Hematoma removal1125 % Incomplete AVM Removal920 % Total AVM removal1330% Decompressive Flap615% 6 (15%) children died within the first 12 hours after the first symptoms

Post op care GA (Sufentanyl, Flunitrazepam) Normothermia (Proparacetamol) Normoxia, Normocapnia Systematic ICP monitoring (Codman, Neurotrend ICP) and SjO2 CCP > 60mmHg (± Dopamine. N=26 (60%)) ± Pentobarbital : 3-5 mg/kg/h ± Nimodipine if Spasm / Doppler (N=26) ± rTpa / EVD (N+9 (20%))

Evolution (GOS) GOSDischargeM6M12 Bad result32 (75%)28 (65%)19 (45%) Death (1)17 (40%) Vegetative (2)000 Severe handicap (3) 15 (35%) 11 (25%)2 (5%) Good result11 (25%)15 (35%)24 (55%) Mild Handicap (4)11 (25%)0,2513 (30%) Normal (5)06 (15%)11 (25%) Hydrocephalus = Epilepsy = 0. Rebleeding = 2

Final result. N=26 FU = 5y TreatmentN ReI°6 E°0 RT°3 ReI° + E°22 ReI° + RT°0 E + RT°7 ReI° + E + RT°1 None7 17 Normal A° at 3 years

Prognostic factors AgeNS SexNS GCSNS LocalizationNS Size / hematomaNS Mydriasisp < 0.01 None0% Death UniL33% Death Bilat75% Death , ,29 Hematomap < 0.01 Group I20% Death Group II50% Death Group III100% Death

Actual acute Management n°1 Emergency if GCS <8 Pre-H Intensive care CT Immediate surgery (Hematoma ± AVM) Post-op aggressive treatment in ICU

Conclusions Acute bleeding is the main problem in the paediatric population Absolute emergency if GCS < 8 Very severe immediate prognosis Higher death rate than in adults Good outcome for the survivors