Vascular Lesion Removal
Why is this surgery done?
This type of surgery is done when your child has a vascular malformation in the brain or spinal cord. A vascular malformation is a rare condition that affects the blood vessels and blood flow in the brain or spinal cord. The condition can involve arteries, veins or both. Children with vascular malformations often undergo surgery to remove the abnormal blood vessels and restore normal blood flow in the brain or spine.
Some vascular malformations can be silent and not require surgery. Others may become unstable and rupture, releasing blood into the brain. A brain bleed, also called hemorrhage, can cause headache, seizures and/or stroke. If the hemorrhage is severe, brain damage or even death may result. The goal of vascular malformation treatment is to prevent a new or recurrent hemorrhage and/or prevent seizures.
Types of vascular malformations include:
- Arteriovenous malformations (AVMs). AVMs are abnormal tangles of arteries and veins that can be found in the brain and spinal cord and are typically present at birth. Instead of being connected by capillaries to slow down blood flow as it travels from arteries to veins, the arteries and veins are tangled together. The high-pressured blood flow from the arteries to the veins can cause a vascular malformation to rupture and bleed and result in neurological deficits and/or seizures from increased pressure on the surrounding brain or spinal cord. They usually are not detected unless they cause seizures, weakness or rupture and bleed into the brain. With each bleed, there can be neurological and/or life threatening complications. There is a 4% per year risk of hemorrhage once an AVM has become symptomatic. Treatment is offered to reduce that risk and subsequent problems associated with additional hemorrhage. Treatment for AVMs can be quite complex, and it is critical that patients with this disorder be managed and surgically treated in a center with extensive AVM experience. Symptoms depend on the severity and location of the brain or spine AVM as well as if the AVM has ruptured. Children may experience:
- Nausea and vomiting
- Persistent headaches
- Weakness on one side of the body or stroke-like symptoms
- Speech changes
- Numbness or tingling of the arms or legs
- Sudden loss of consciousness (with rupture)
- Cavernous malformations. Cerebral cavernous malformations (CCMs) consist of abnormal collections of thin-walled small blood vessels (capillaries) that displace normal tissue in the brain or spinal cord. Cavernous malformations are fragile, prone to bleeding and may cause seizures and neurological deficits if they bleed. Hereditary forms of cerebral cavernous malformations can occur, resulting from genetic mutations in one of three disease genes: CCM1, CCM2 or CCM3. Patients with hereditary forms of CCM often present with numerous cavernous malformations.
- Venous angiomas. These are made up of abnormal veins that enlarge and twist together. They can be associated with cavernous malformations. They rarely bleed and rarely, if ever, need to be removed.
- Vein of Galen malformations (VOGMs). This is a specific type of arteriovenous malformation that occurs when arteries within the brain connect directly to a very large vein in the center of the brain called the Vein of Galen. VOGMs typically appear during fetal development and can be found before birth during ultrasounds. Babies diagnosed immediately after birth may have heart failure due to an abnormally high level of blood flow through the VOGM that causes strain on an infant’s heart and lungs. Early detection and treatment are critical for the best possible outcome for the baby. Other signs and symptoms of VOGMs include unusually prominent veins on the face and scalp, visible or palpable pulsations on the head, abnormally increased head circumference, failure to thrive or meet developmental milestones and bleeding in the brain, in rare or severe cases. Treatment of VOGMs is provided through the collaboration of neurointerventional radiologists, neonatologists and cardiologists to offer a comprehensive and individualized approach to care. VOGMs require a minimally invasive procedure for embolization, which is performed in conjunction with a cerebral angiogram, using a process of injecting a special material or coils into a blood vessel to cut off blood flow to the vascular malformation. Depending on the size and severity of the malformation, there may need to be multiple embolization procedures.
How is the surgery done?
Treatment varies based on the type, size, location, symptoms and severity of the vascular malformation. Our team offers a comprehensive approach with a multitude of possible treatment interventions or combination of treatments. These include medical management, interventional radiographic techniques (such as embolization), open microsurgical resection and radiosurgery.
- Embolization is performed along with a conventional cerebral angiogram. It can be used in addition to open microsurgery to help reduce the risks of open surgery. Occasionally it will be utilized in the early phase of treatment if there is an aneurysm (an area of outward bulging on a weak spot of the wall of an artery that places it at risk for rupture and associated life-threatening hemorrhage) in the AVM. During embolizaton, a specialized interventional neuroradiologist inserts a thin plastic catheter into an artery in your child’s groin. The catheter is guided into the AVM and a special material is injected that shuts off the artery and reduces the flow of blood to the vascular abnormality.
- Neurosurgery or open microsurgery. Surgery for vascular malformations requires a highly specialized and meticulous approach and depends on the location of the vascular malformation (brain or spine). This approach involves making an opening in the bone, removing a piece of bone followed by its replacement at the end of the operation, and using a microscope to visualize the abnormal blood vessels that make up the malformation and remove it. Your child will need to stay in the hospital for several days, with the length of stay determined by the extent of surgery. Your child will have an angiogram after surgery to make sure that the treatment has been effective.
- Radiosurgery. This is another type of surgery for arteriovenous malformations of the brain. Radiosurgery is a unique form of high-dose radiation delivered to the brain in a very focused location, allowing the treatment of a specific abnormality while avoiding injury to normal brain tissue. Radiosurgery is considered minimally invasive and is performed as a day procedure. Radiation causes the blood vessels to thicken over time and eventually become narrowed to the point that they close up completely. After treatment with radiosurgery, it takes up to 2 – 3 years for the AVM to close. The procedure is typically reserved for patients with AVMs in areas of the brain that are important for function and/or difficult to reach with microsurgery, patients who have medical conditions that further complicate surgery or families that do not want an open operation. However, not all children with an AVM are candidates for this procedure.
What are my risks? What are common complications?
Risks of the surgery include but are not limited to:
- Cerebrospinal fluid leak
- Possible damage to the surrounding brain or spinal cord tissue, which may lead to a decrease in your child’s ability to walk, talk and control movements
Risks without surgery include:
- Rupture of the vascular malformation and all of the associated consequences listed above
- Anxiety or worry about spontaneous rupture of the vascular malformation
What do I need to know before surgery?
If your child experiences severe worsening headache, seizures, numbness or tingling in the arms or legs, trouble walking or talking, changes in vision and/or significant nausea or vomiting, you should seek immediate medical attention.
If your child is diagnosed with a vascular malformation, the pediatrician will refer them to a pediatric neurosurgeon for consultation. You will then meet with the neurosurgeon to discuss the vascular malformation and need for treatment. Questions and concerns regarding the type(s) of treatment offered will be addressed at that appointment. If any additional tests are needed, they will be explained and ordered at that time.
You will receive communication before coming to the hospital with specifics on where to go the day of surgery and instructions for the day before and day of surgery. This information will include details about home medications and when to stop eating and drinking.
The length of surgery will depend on the degree of difficulty of the vascular malformation, and your child will spend at least 2 – 3 nights in the hospital. The first night will be in the pediatric intensive care unit (PICU) for close monitoring. Your child will come out of surgery very sleepy and their medical team will likely give them medicine that makes them extra sleepy for the first 12 hours after surgery to help with pain control.
Your child will be given intravenous (IV) fluids, pain medications and anti-nausea medication until they are able to take medications by mouth. IV antibiotics will be given for 24 hours after surgery. Steroids will be ordered for the first 48 hours through the IV. Due to the fact steroids can upset the stomach, your child will be given medication to help to decrease stomach upset. Your child will be started on a stool softener immediately after surgery to prevent constipation. A seizure medication is also given to protect against possible seizures. Your child may go home on this medication and may need to continue it for several months.
Your child will have a rubber tube in their bladder (Foley catheter) to drain their urine while sedated and additional monitoring devices to closely track their blood pressure and heart rate. The Foley catheter will remain in place until the child can get out of bed to go to the bathroom.
Your child will be allowed to drink and eat slowly as soon as they are able, and they will be allowed to get up out of bed as soon as they are awake and the extra monitoring devices and bladder catheter have been removed.
In some circumstances, your child may have a cerebrospinal fluid (CSF) drainage tube connected to a sterile collection bag to relieve pressure on the brain, depending on whether hydrocephalus was present prior to surgery and whether or not the vascular malformation had ruptured into the ventricle. This external ventricular drain (EVD) helps to regulate the pressure caused by an increase in CSF. We will start to raise the drain within a few days and remove it if your child’s brain is able to maintain a normal pressure.
Your child will be discharged from the hospital once their pain is well controlled with oral pain medications and they are able to eat and drink, go to the bathroom and walk around the room.
The pediatric neurosurgery providers at Goodman Campbell Brain and Spine are specially trained on this diagnosis and are experts in the care of vascular lesions. We know it can be a scary time, and we have a team of medical professionals who are available to answer any questions or discuss any concerns you might have.
General discharge instructions
In order to be discharged from the hospital, your child will need to:
- Be able to urinate without any problems
- Be able to tolerate oral/tube feeds without vomiting
- Have pain controlled with oral pain medications
- Pass gas and have a bowel movement
- Be fever free for 24 hours
The course and length of stay is variable and can range from 3 – 5 days to up to a month depending on any complications that were present prior to or after the surgery.
A child is usually out of school for at least two weeks while they heal. Some children may require a more specialized timeframe.
A child is not to participate in any sports, and must keep their feet on the ground at all times (no swinging, jumping, climbing or running) for 4 – 6 weeks after surgery, until they are cleared to do so during a follow-up visit.
What should I expect while recovering?
There will be a follow-up appointment with neurosurgery two weeks after the surgery or sooner if needed.
Reasons to call the neurosurgery office include:
- The incision has any swelling, redness or drainage
- Fever of 101.5 or higher
- Persistent vomiting
- Worsening pain
- Trouble going to the bathroom
- Any numbness, tingling or weakness in the arms or legs
The region of the incision is typically sore after surgery. This should gradually improve and be relieved by the oral pain medications prescribed for your child.
Tiredness and fatigue are also very common and will gradually improve with time. It is common for it to take up to three months before your child feels “back to normal.” Make sure they have plenty of rest during the day and eat healthy foods. (Avoid candy, soda and fast food.) Set a regular bedtime and wake-up time to ensure they get plenty of sleep.
Possible physical therapy exercises
Your child will be evaluated by therapists (physical, occupational and speech), typically on the first day after surgery, to help them with walking and speaking.
Your child may need more outpatient therapy once discharged from the hospital. The social worker will help to set this up as close as possible to your home.