Introduction: Optimal definitive management of a ruptured AVM, by either surgical, radiosurgical and/or endovascular techniques, is best achieved after resorption of the hematoma and its attendant inflammation. Dangerously elevated intracranial pressure, however, may necessitate treatment, often temporizing, prior to hematoma resolution. Surgical evacuation may be complicated by further damage to the edematous brain and/or bleeding from a poorly defined AVM.
The use of barbiturates to control elevated intracranial pressure in children with traumatic brain injury is well established. In the setting of a ruptured AVM, however, the use of barbiturates is less well described.
Methods: A retrospective chart review of pediatric patients with intracranial hypertension from a ruptured AVM who received barbiturate therapy from 1997 to 2015 was performed. Data regarding efficacy, complications and outcome were collected.
Results: Twenty-two pediatric patients (M:F 15:7; ages 4 - 17 years) are described. Mean pentobarbital infusion duration, ICU duration and hospital stay were 6.36 days, 21.7 days and 27.6 days respectively. Two patients experienced early intractable intracranial hypertension and progressed rapidly to brain death. One patient exhibited poorly controlled intracranial pressure and underwent hematoma evacuation and decompressive craniectomy on post-hemorrhage day 4. Eighteen of 20 survivors required vasopressor support for barbiturate induced hypotension. Complications observed during their ICU stays included pneumonia (40.9%), sepsis (27.2%), pancreatitis (22.7%) and urinary tract infections (18.1%).
Various outcome scores revealed favorable neurologic outcomes amongst survivors with none appearing to have deteriorated neurologically during the period of medical ICP treatment. All patients subsequently underwent definitive AVM treatment (microsurgery, radiosurgery, endovascular or combined).
Conclusions: Barbiturate therapy appears effective in controlling intracranial hypertension and may avoid the need for emergent craniotomy in the setting of a ruptured AVM in pediatric patients. Complications related to systemic hypotension and infections are common and should be anticipated.
Patient Care: This research should improve patient care by providing practitioners with data regarding the efficacy and complications of the use of barbiturate coma in children with ruptured AVMs and raised intracranial pressure.
Learning Objectives: By the conclusion of this session participates will consider barbiturate therapy in their patients with ruptured AVMs and be aware of the potential advantages and complications associated with this modality.