Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Jul 2010
ReviewDiagnosis and management of arteriovenous malformations in children.
Arteriovenous malformation (AVM) is the most common cause of spontaneous intraparenchymal hemorrhage in children, excluding hemorrhages of prematurity and early infancy. Because most children diagnosed with an AVM undergo initial treatment emergently, the natural history of AVMs in the pediatric population is not well understood. Most pediatric AVMs do not come to clinical attention unless they hemorrhage. ⋯ Microsurgical resection remains the gold standard for treatment of accessible pediatric AVMs, especially in cases that present with intracranial hemorrhage. Newer modalities, such as embolization and radiosurgery, have provided additional tools to help children with large or deep-seated lesions that would be deemed unresectable with microsurgical techniques alone. Long-term follow-up with repeated diagnostic imaging is important despite complete obliteration of the lesion to rule out the small possibility of AVM recurrence.
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Cavernous malformations (CMs) are vascular lesions found in the central nervous system (CNS) and throughout the body and have been called cavernomas, cavernous angiomas, and cavernous hemangiomas. This article discusses the epidemiology, natural history, diagnosis, treatment and follow-up of children who are found to harbor these lesions. CMs affect children by causing hemorrhage, seizure, focal neurologic deficits, and headache. ⋯ Patients with multiple lesions should be referred for genetic evaluation and counseling. Individuals with symptomatic, growing, or hemorrhagic malformations should be considered for surgical resection. Close follow-up after diagnosis and treatment is helpful to identify lesion progression or recurrence.
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Neurosurg. Clin. N. Am. · Apr 2010
ReviewCerebral salt wasting: pathophysiology, diagnosis, and treatment.
Cerebral salt wasting (CSW) is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. The mechanisms underlying CSW have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. ⋯ Volume status, but not serum and urine electrolytes and osmolality, is crucial for making this distinction. Volume and sodium repletion are the goals of treatment of patients with CSW, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids.
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Cerebral vasospasm is a cause of significant morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Most cases of vasospasm can be managed medically. Medical strategies for treatment include hemodynamic augmentation to improve cerebral perfusion pressure and medical therapy to prevent or reduce cerebral vasospasm. ⋯ Balloon angioplasty is an effective technique in treating vasospasm and results in durable clinical improvement. It should be used judiciously, however, given a small risk of vessel rupture associated with intracranial angioplasty. The goal of angioplasty should be improvement of vessel caliber to augment flow rather than to achieve a picture-perfect result.