Initial Management at Presentation
- Varies with age: Treatment strategies for DAVF depend on the age and type of lesion involved. A thoughtful individual approach should be designed by neurosurgeons and neuroradiologists taking care of these children.
- Observe Type 1 lesions: Asymptomatic DAVFs, especially type I, can be observed. In severe symptomatic cases (i.e chronic disabling tinnitus), treatment can be considered.
- Treat signs of venous hypertension: Those showing cortical venous reflux and variceal veins, particularly if symptomatic, should be treated with endovascular procedures, open surgery or a combination of both (4,20). In general, endovascular procedures are the first-line treatment(13). Nevertheless, some locations such as ethmoidal and tentorial DAVFs might be more suitable for open surgical treatment. Radiosurgery might also play a role in select cases(21,26).
- Stereotactic radiosurgery: This is a treatment option that might be reserved for children with low-risk DAVFs without venous reflux. Effect of radiosurgery is delayed (up to 36 months) and obliteration rates have been reported to be around 55% to 80%. In addition, secondary effects, such as compromise to mental development and rarely tumor formation, should be strongly considered before indicating radiosurgery in children(21,26).
- Serial Imaging: As these lesions often recur, especially if partially treated, a serial imaging follow-up plan should be established(22), such as every 6 months for the first 2 years and yearly after that for an additional 5 years.
- Recurring Symptoms: Imaging should also be prompted if symptoms recur.
- Imaging: It is generally advisable to start with non-invasive imaging, such as MRA with contrast, and to continue with conventional angiography if the clinical and non-invasive studies suggest recurrence.