1. Intracranial Haemorrhage in Children : Surgical Experience Paediatric Vascular Diseases

2. P. Lasjaunias AVM

3. 2 completely different series Bicêtre. P.Lasjaunias 102 PAVMs 1982-1992 Secondary care Diagnosis / Bleeding = 47% Necker 103 PAVMs 1996 - 2000 Primary care 98 Haemorrhage 4 Epilepsy 1 Exophtalmia Humphreys.Toronto. 1949-1995 160 children

4. Necker 2002 * * 16 millions inhabitants 3.5 millions children 16 millions inhabitants 3.5 millions children 1/100 000 children /year

5. Necker 1996-2000 103 PAVMs SR : 1.2 : 1 (M:F) Mean age : 9.7 (±3.3) Median age : 9.5 (1-15) Bleeding : 98 (97%) GCS ≤ 8 = 43 Deaths = 17 (17%, 40%) Diagnosis/Haemorrhage 47% (Lasjaunias 1992) 79% (Humphreys1996) 55-77% (Celli 1984) GCS ≤8 37% (Humphreys1996) 23-31% (Celli 1984) Mortality 21% (Humphreys1996) 7-13% (Celli 1984)

9. Haemorrages in cerebral AVM in children and adults Children %Adults % Frequency55-7737-41 Mortality7-173-10 Coma23-3111-17 Immediate Morbidity78-8950-53

10. Symptoms N% Headaches2865% Vomiting1330% Seizures25% Acute Neurological Deficit1125%

11. Primary care (1) SAMU (paramedics) NTI, Ventilation, Sedation Emergency Room Central Line Osmotherapy : Manitol 20% (5mg/kg) HyperT. Saline (3ml/kg) Plasmatic osmolarity : 300-310 mOsm/l

12. Initial GCS GCSN% GCS 3410% GCS 41535% GCS 5920% GCS 625% GCS 7615% GCS 8615%

13. Initial Care (2) RadiologyN CT15 CT w Contrast27 MR1 Angiogram9

15. Location N% SAH410% Frontal25% Occipital25% Temporo-parietal1330% Deep seated1125% Posterior fossa1125%

16. Groupe A N= 17 (40%) Groupe B N= 22 (50%) Groupe C N= 4 (10%)

17. Contrast ?

18. Emergency MR

19. Initial Treatment TreatmentN% EVD10+1250 % Hematoma removal1125 % Incomplete AVM Removal920 % Total AVM removal1330% Decompressive Flap615% 6 (15%) children died within the first 12 hours after the first symptoms

20. Post op care GA (Sufentanyl, Flunitrazepam) Normothermia (Proparacetamol) Normoxia, Normocapnia Systematic ICP monitoring (Codman, Neurotrend ICP) and SjO2 CCP > 60mmHg (± Dopamine. N=26 (60%)) ± Pentobarbital : 3-5 mg/kg/h ± Nimodipine if Spasm / Doppler (N=26) ± rTpa / EVD (N+9 (20%))

21. Evolution (GOS) GOSDischargeM6M12 Bad result32 (75%)28 (65%)19 (45%) Death (1)17 (40%) Vegetative (2)000 Severe handicap (3) 15 (35%) 11 (25%)2 (5%) Good result11 (25%)15 (35%)24 (55%) Mild Handicap (4)11 (25%)0,2513 (30%) Normal (5)06 (15%)11 (25%) Hydrocephalus = Epilepsy = 0. Rebleeding = 2

22. Final result. N=26 FU = 5y TreatmentN ReI°6 E°0 RT°3 ReI° + E°22 ReI° + RT°0 E + RT°7 ReI° + E + RT°1 None7 17 Normal A° at 3 years

23. Prognostic factors AgeNS SexNS GCSNS LocalizationNS Size / hematomaNS Mydriasisp < 0.01 None0% Death UniL33% Death Bilat75% Death 1996 - 19980,53 1999 - 20000,29 Hematomap < 0.01 Group I20% Death Group II50% Death Group III100% Death

24. Actual acute Management n°1 Emergency if GCS <8 Pre-H Intensive care CT Immediate surgery (Hematoma ± AVM) Post-op aggressive treatment in ICU

25. Conclusions Acute bleeding is the main problem in the paediatric population Absolute emergency if GCS < 8 Very severe immediate prognosis Higher death rate than in adults Good outcome for the survivors