Paediatric Cerebral Arteriovenous Malformation: Outcomes from a Singapore Children's Hospital.

OBJECTIVES: Paediatric brain arteriovenous malformation (bAVM) is a rare and distinct clinical entity. There is a growing body of literature that support the success of multimodality approaches for this difficult condition. The authors aim to firstly, describe our institutional experience with a consecutive series of patients and next, corroborate our results with current literature. MATERIAL AND METHODS: This is a single institution, retrospective study conducted over a 20-year period. Patients less than 19 years old with bAVM were included. Variables of interest included patient demographics, clinical presentation, neuroimaging features, bAVM characteristics and treatment modality. Functional outcomes were measured with modified Rankin scale (mRS). RESULTS: There were 58 paediatric bAVMs, presenting at a mean age of 8.7 ± 4.2 years, and followed up for a mean duration of 7.7 years. Thirty-six patients (62.1%) underwent microsurgical resection, 10 patients had stereotactic radiosurgery (17.2%) and 2 patients had endovascular treatment (3.4%). 50 patients (86.2%) had a favourable outcome at 1-year follow up. Microsurgical resection and SRS had similar obliteration rates (resection 83.3%; SRS 80.0%) and recurrence (resection 10.0%; SRS 12.5%). There were 6 cases of bAVM recurrence (12.8%). This subgroup was noted to be less than 7.5 years old at presentation (OR 15.0, 95% CI 1.56 - 144), and less likely to present with bAVM rupture (OR 0.11, 95% CI 0.01 - 0.96). CONCLUSION: This study describes our experience in managing paediatric bAVM, whereby monomodal therapy can still be effective. Of note, we also demonstrate the role of extended surveillance to detect recurrence.

Aqueductal Compression by Dilated Virchow-Robin Spaces in the Mesencephalic-Pontine Region Presenting with Symptoms Mimicking Normal Pressure Hydrocephalus: A Case Report and Review of Literature.

BACKGROUND: Dilatation of Virchow-Robin spaces (dVRS) have been described in the development of hydrocephalic syndromes. We report an unusual case of a type III dVRS presenting as a mimic of normal pressure hydrocephalus (NPH), due to distortion at the level of the cerebral aqueduct. CASE DESCRIPTION: A 59-year-old woman presented with mild traumatic brain injury and possible NPH, due to a history of progressive gait disturbance, recurrent falls, and cognitive decline over a year, in the context of ventriculomegaly. Detailed structural imaging of the brain revealed multiple dilated cystic lesions consistent with dVRS causing distortion at the level of the cerebral aqueduct. Cerebrospinal fluid examination was negative for infection. The patient was treated with endoscopic third ventriculostomy; at 12 months postoperatively, she demonstrated a sustained improvement in gait and stabilization of cognitive decline. CONCLUSIONS: This is an illustrative case of a subacute obstructive hydrocephalus due to a collection of periaqueductal dVRS, leading to an insidious clinical presentation mimicking NPH. We reviewed the literature for key clinical presentations and describe neuroanatomical considerations as well as primary treatment strategies. Various hydrocephalic syndromes may present with classic symptoms from Hakim's triad; such symptoms are not specific to idiopathic NPH. Both endoscopic third ventriculostomy and shunting may be efficacious. In our case, dVRS may serve as both a cause of and compensatory mechanism in a subacute obstructive hydrocephalus of unknown etiology. Our case highlights the need to understand the neuroanatomy of aberrant cerebrospinal fluid spaces in hydrocephalic syndromes. Further studies of dVRS would provide valuable insights into the pathogenesis of hydrocephalus.