Awake resection of a right motor cortex arteriovenous malformation in a pediatric patient: A case report and review of the literature.

Background: Intracranial arteriovenous malformations (AVMs) are extremely rare in the pediatric population, with an estimated prevalence of 0.014-0.028%. About 75-80% of pediatric AVMs present with intracranial hemorrhage, a source of significant morbidity and mortality. Awake craniotomy (AC) has become the standard approach for resecting eloquent area intracranial lesions in the adult population. Its use, however remains limited in the pediatric population and has very rarely been reported for an AVM of the motor cortex in this age group.

Case description: We report the case of a 17-year-old, right-handed boy who presented to our setup with a 2-month history of left-sided hemiparesis and left facial hypoesthesia following an episode of acute loss of consciousness (ALOC) while playing football. A computed tomography scan done after ALOC revealed an AVM in the right frontoparietal cortex with associated acute hemorrhage. Digital subtraction angiography (DSA) was done which revealed a right-sided grade II AVM with arterial supply from the right middle cerebral artery and venous drainage into the superior sagittal and cavernous sinuses. The patient underwent elective neuronavigation-guided right frontoparietal AC and resection of AVM. Postoperative DSA revealed no residual disease. The patient's neurologic deficits showed improvement in the first few days following surgery. He was discharged with advice to follow up in a neurosurgery clinic to monitor his postoperative recovery and ensure compliance with physiotherapy.

Conclusion: This case represents only the second pediatric patient in the available medical literature to have ever undergone AC for intracranial AVM resection. Pediatric AVMs are a rare entity and pose the risk of significant morbidity and mortality. Awake surgery has the potential to reduce iatrogenic neurological deficits in the pediatric population significantly. More work must be done to increase pediatric patient compliance with awake surgery.