CASE REPORT
Las malformaciones arteriovenosas cerebrales (MAVs) representan un reto terapéutico por su anatomía compleja y riesgo considerable de hemorragia. Las MAVs de tallo cerebral (MAVt) son críticas por su proximidad a estructuras elocuentes. Recientes avances tecnológicos como la videoangiografía intraoperatoria con verde de indocianina (VIC) mejoran la precisión y seguridad quirurgicas en casos seleccionados. Presentamos el caso de una paciente pediátrica con MAVt llevada a embolización y resección microquirúrgica con videoangiografía VIC. Esta técnica permitió la visualización al instante de vasos nutricios y aferentes, facilitó la oclusión precisa y minimizó el riesgo de déficit. Las imágenes postoperatorias confirmaron la resección parcial del nido y el clipaje de un aneurisma. Se realizó una revisión narrativa para contextualizar este enfoque. La evidencia actual respalda la videoangiografía VIC para realizar decisiones intraoperatorias, reducir complicaciones y mejorar resultados quirúrgicos en MAVs. Aunque las clasificaciones como Spetzler-Martin y de Oliveira orientan la toma de decisiones estratificando el riesgo; el manejo debe individualizarse mediante estrategias multimodales, frecuentemente requiriendo estrategias multimodales. Este caso ilustra la viabilidad de la videoangiografía VIC intraoperatoria para las MAVt pediátricas, ofreciendo mayor precisión en la identificación y oclusión vascular. Se necesitan estudios para determinar protocolos y resultados a largo plazo en pacientes pediátricos.
Brain arteriovenous malformations (AVMs) represent a significant therapeutic challenge due to their complex anatomy and considerable risk of hemorrhage. Brainstem AVMs (bsAVMs) are particularly critical because of their proximity to eloquent structures. Recent technological advances, including intraoperative indocyanine green (ICG) videoangiography, have improved surgical precision and safety in selected cases. We report the case of a pediatric patient with a bsAVM who underwent endovascular embolization and microsurgical resection assisted by intraoperative (ICG) videoangiography. This technique allowed real-time visualization of feeding and draining vessels, which facilitated accurate occlusion and minimized the risk of neurological deficit. Postoperative imaging confirmed partial resection of the nidus and clipping of an aneurysm. A narrative literature review was conducted to contextualize this approach. Current evidence supports the role of ICG videoangiography in enhancing intraoperative decision-making, reducing complications, and improving outcomes in AVM surgery. Even so, classifications such as Spetzler-Martin and de Oliveira guide decision-making through risk stratification; patient management remains individualized, often requiring multimodal strategies. This case illustrates the feasibility and utility of ICG videoangiography in pediatric brainstem AVM surgery, offering greater precision in vascular identification and occlusion. Further studies are needed to establish standardized protocols and long-term outcomes for pediatric patients.
3. Silva AHD, James G. Natural history and clinical manifestation of Pediatric Brain Arteriovenous Malformations. J Korean Neurosurg Soc. 2024;67(3):280-8. https://doi.org/10.3340/jkns.2024.0037. PMid:38720544.
4. Zyck S, Davidson CL, Sampath R. Arteriovenous malformations of the central nervous system. In: Mintz J, Mintz BL, Jaff MR, editors. Atlas of clinical vascular medicine. Hoboken: John Wiley & Sons; 2024. https://doi.org/10.1002/9781118618189.ch75.
5. Stapf C, Mast H, Sciacca RR, et al. Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology. 2006;66(9):1350-5. https://doi.org/10.1212/01.wnl.0000210524.68507.87. PMid:16682666.
6. Yang W, Feghali J, Sattari SA, Hung AL, Chen Y, Huang J. The Natural history of hemorrhage in brain arteriovenous malformations-poisson regression analysis of 1066 patients in a single institution. Neurosurgery. 2024;94(2):389-98. https://doi.org/10.1227/neu.0000000000002674. PMid:37681967.
7. Magro E, Darsaut TE, Mezui EDO, et al. Arteriovenous malformations of the posterior fossa: a systematic review. Acta Neurochir. 2020;162(4):905-10. https://doi.org/10.1007/s00701-020-04260-6. PMid:32067118.
8. Almeida JP, Medina R, Tamargo RJ. Management of posterior fossa arteriovenous malformations. Surg Neurol Int. 2015;6(1):31. https://doi.org/10.4103/2152-7806.152140. PMid:25745586.
9. Khaw AV, Mohr JP, Sciacca RR, et al. Association of infratentorial brain arteriovenous malformations with hemorrhage at initial presentation. Stroke. 2004;35(3):660-3. https://doi.org/10.1161/01. STR.0000117093.59726.F9. PMid:14752127.
10. Arnaout OM, Gross BA, Eddleman CS, Bendok BR, Getch CC, Batjer HH. Posterior fossa arteriovenous malformations. Neurosurg Focus. 2009;26(5):e12. https://doi.org/10.3171/2009.2.FOCUS0914. PMid:19408990.
11. Madhugiri VS, Teo MKC, Vavao J, Bell-Stephens T, Steinberg GK. Brainstem arteriovenous malformations: lesion characteristics and treatment outcomes. J Neurosurg. 2018;128(1):126-36. https://doi.
org/10.3171/2016.9.JNS16943. PMid:28298018.
12. Aguiar PH, Stefani MA, Isolan GR, Zicarelli CA, Antunes ACM. Cerebral arteriovenous malformations: integrated global management and therapeutic. J Bras Neurocir. 2012;23(4):301-15. https://doi. org/10.22290/jbnc.v23i4.1215.
13. Solomon RA, Connolly ES Jr. Arteriovenous malformations of the brain. N Engl J Med. 2017;376(19):1859-66. https://doi.org/10.1056/ NEJMra1607407. PMid:28489992.
14. Lawton MT, Rutledge WC, Kim H, et al. Brain arteriovenous malformations. Nat Rev Dis Primers. 2015;1(1):15008. https://doi. org/10.1038/nrdp.2015.8. PMid:27188382.
15. de Liyis BG, Arini AAIK, Karuniamaya CP, et al. Risk of intracranial hemorrhage in brain arteriovenous malformations: a systematic review and meta-analysis. J Neurol. 2024;271(5):2274-84. https://doi. org/10.1007/s00415-024-12235-1. PMid:38396103.
16. Mullan S, Mojtahedi S, Johnson DL, Macdonald RL. Embryological basis of some aspects of cerebral vascular fistulas and malformations. J Neurosurg. 1996;85(1):1-8. https://doi.org/10.3171/jns.1996.85.1.0001. PMid:8683257.
17. Mouchtouris N, Jabbour PM, Starke RM, et al. Biology of cerebral arteriovenous malformations with a focus on inflammation. J Cereb Blood Flow Metab. 2015;35(2):167-75. https://doi.org/10.1038/ jcbfm.2014.179. PMid:25407267.
18. Rinaldi M, Mezzano E, Berra MS, Parés HR, Olocco RV, Papalini FR. Arteriovenous malformations: checking and descriptive analysis of 52 AVMs treated for the 2000-2010 period. Surg Neurol Int. 2015;6 (Suppl 20):S511-23. https://doi.org/10.4103/2152-7806.167198. PMid:26600984.
19. Laakso A, Hernesniemi J. Arteriovenous malformations: epidemiology and clinical presentation. Neurosurg Clin N Am. 2012;23(1):1-6. https://doi.org/10.1016/j.nec.2011.09.012. PMid:22107853.
20. Abecassis IJ, Xu DS, Batjer HH, Bendok BR. Natural history of brain arteriovenous malformations: a systematic review. Neurosurg Focus. 2014;37(3):E7. https://doi.org/10.3171/2014.6.FOCUS14250. PMid:25175445.
21. Han SJ, Englot DJ, Kim H, Lawton MT. Brainstem arteriovenous malformations: anatomical subtypes, assessment of “occlusion in situ” technique, and microsurgical results. J Neurosurg. 2015;122(1):107-17. https://doi.org/10.3171/2014.8.JNS1483. PMid:25343188.
22. Aygun N, Masaryk TJ. Diagnostic imaging for intracerebral hemorrhage. Neurosurg Clin N Am. 2002;13(3):313-34, vi. https:// doi.org/10.1016/S1042-3680(02)00009-8. PMid:12486921.
23. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2015;46(7):2032-60. https://doi. org/10.1161/STR.0000000000000069. PMid:26022637.
24. Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage.
Ann Emerg Med. 2008;51(6):697-703. https://doi.org/10.1016/j.
annemergmed.2007.10.007. PMid:18207607.
25. Josephson CB, White PM, Krishan A, Al-Shahi Salman R. Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Cochrane Database Syst Rev.
2014;2014(9):CD009372. https://doi.org/10.1002/14651858.CD009372. pub2. PMid:25177839.
26. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476-83. https://doi.org/10.3171/ jns.1986.65.4.0476. PMid:3760956.
27. Oliveira E, Tedeschi H, Raso J. Multidisciplinary approach to arteriovenous malformations. Neurol Med Chir. 1998;38(Suppl):177-85. https://doi.org/10.2176/nmc.38.suppl_177. PMid:10235003.
28. Spetzler RF, Ponce FA. A 3-tier classification of cerebral arteriovenous malformations. Clinical article. J Neurosurg. 2011;114(3):842-9. https:// doi.org/10.3171/2010.8.JNS10663. PMid:20932095.
29. Hafez A, Koroknay-Pál P, Oulasvirta E, et al. The application of the novel grading scale (Lawton-young grading system) to predict the outcome of brain arteriovenous malformation. Neurosurgery. 2019;84(2):529-36. https://doi.org/10.1093/neuros/nyy153. PMid:29733392.
30. Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4): 702-13. https://doi.org/10.1227/01.NEU.0000367555.16733.E1. PMid:20190666.
31. Pierot L, Cognard C, Herbreteau D, et al. Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO). Eur Radiol. 2013;23(10):2838-45. https://doi.org/10.1007/s00330-013-2870-6. PMid:23652849.
32. Elkordy A, Endo H, Sato K, et al. Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations. J Neurosurg. 2017;126(4):1114-22. https://doi.org/10.3171/2016.2.JNS152370. PMid:27153173.
33. Endo H, Osawa SI, Matsumoto Y, et al. Embolization of ruptured arteriovenous malformations in the cerebellopontine angle cistern. Neurosurg Rev. 2018;41(1):173-82. https://doi.org/10.1007/s10143017-0832-1. PMid:28220368.
34. Omodaka S, Endo H, Fujimura M, et al. High-grade cerebral arteriovenous malformation treated with targeted embolization of a ruptured site: wall enhancement of an intranidal aneurysm as a sign of ruptured site. Neurol Med Chir. 2015;55(10):813-7. https://doi. org/10.2176/nmc.cr.2015-0052. PMid:26369871.
35. Dumont TM, Kan P, Snyder KV, Hopkins LN, Siddiqui AH, Levy EI. A proposed grading system for endovascular treatment of cerebral arteriovenous malformations: buffalo score. Surg Neurol Int. 2015;6(1):3. https://doi.org/10.4103/2152-7806.148847. PMid:25657856.
36. Pulli B, Stapleton CJ, Walcott BP, et al. Comparison of predictive grading systems for procedural risk in endovascular treatment of brain arteriovenous malformations: analysis of 104 consecutive patients. J Neurosurg. 2019;133(2):342-50. https://doi. org/10.3171/2019.4.JNS19266. PMid:31200386.
37. Chen CJ, Norat P, Ding D, et al. Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes. Neurosurg Focus. 2018;45(1):E13. https://doi. org/10.3171/2018.3.FOCUS18113. PMid:29961383.
38. Sugiyama T, Grasso G, Torregrossa F, Fujimura M. Current concepts and perspectives on brain arteriovenous malformations: a review of pathogenesis and multidisciplinary treatment. World Neurosurg. 2022;159:314-26. https://doi.org/10.1016/j.wneu.2021.07.106.
PMid:34339893.
39. Han H, Gao D, Ma L, et al. Long-term outcomes of microsurgery and stereotactic radiosurgery as the first-line treatment for arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data. Int J Surg. 2023;109(12):3983-92. https://doi.org/10.1097/JS9.0000000000000751. PMid:37720924.
40. Foster CH, Morone PJ, Tomlinson SB, Cohen-Gadol AA. Application of indocyanine green during arteriovenous malformation surgery: evidence, techniques, and practical pearls. Front Surg. 2019;6:70. https:// doi.org/10.3389/fsurg.2019.00070. PMid:31921884.
41. Shimada K, Miyake K, Yamaguchi I, et al. Efficacy of utilizing both 3-dimensional multimodal fusion image and intra-arterial indocyanine green videoangiography in cerebral arteriovenous malformation surgery. World Neurosurg. 2023;169:e260-9. https://doi.org/10.1016/j. wneu.2022.10.121. PMid:36332776.
42. Chen Y, Li R, Ma L, et al. Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience. Stroke Vasc Neurol. 2021;6(1):65-73. https:// doi.org/10.1136/svn-2020-000407. PMid:32928999.
43. Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383(9917):614-21. https://doi.org/10.1016/S01406736(13)62302-8. PMid:24268105.
44. Ravindra VM, Bollo RJ, Eli IM, et al. A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits. J Neurosurg Pediatr. 2019;24(1):1-8. https://doi.org/10.3171/2019.2.PEDS18731. PMid:30952115.
45. Hsiao MC, Tsuei YS, Pan HC, et al. Long-Term outcomes of pediatric cerebral arteriovenous malformations: a ten-year single-center retrospective study. Medicina (Kaunas). 2025;61(7):1177. https://doi. org/10.3390/medicina61071177. PMid:40731807.
1Department of Neuroscience, Clínica del Country and Clínica la Colina, Bogotá, Colombia.
Received Feb 12, 2026
Corrected May 4, 2026
Accepted May 5, 2026
