Abstract Body: Introduction: Pediatric cerebral arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage (ICH) in children. Gross surgical extirpation is essential to reducing the likelihood of recurrence and rupture. Use of intraoperative angiography provides real-time information about the extent of resection and may reduce the likelihood of unidentified residual pathology.

Objective: This study aimed to review our institutional experience with intraoperative angiography in the setting of pediatric AVM surgery with attention towards procedural safety and need for further intervention.

Methods: A retrospective review was performed for all patients undergoing cerebral AVM resection with intraoperative angiography by transfemoral access at our institution between July 1997 and October 2024. Patient records and imaging were reviewed.

Results: Twenty one children (8 female, 13 male) underwent 22 surgeries for cerebral AVM resection. 10% carried a previous diagnosis of cerebral AVM with prior treatment, such as irradiation or nBCA embolization. 71% presented with ruptured AVMs and associated ICH. Of the ruptured AVMs, 27% presented with associated perinidal or flow-related aneurysms. 95% underwent pre-operative angiography, with 63% requiring glue embolization. Of 21 AVMs, 24% were Spetzler-Martin grade 1, 33% grade 2, 23% grade 3, and 9% were grade 4. There were no Spetzler-Martin grade 5 lesions (Table 1). Intraoperative angiography demonstrated gross debulking of known AVM without residual in 21/22 cases. No patients experienced angiography-related complications, including groin pseudoaneurysm, vessel dissection, or stroke. Mean length of inpatient stay following resection was 5.6 days. Mean length of followup was 26.5 months. Two patients demonstrated evidence of radiographic recurrence requiring further treatment.

Conclusions: Intraoperative cerebral angiography represents a safe, effective modality to confirm surgical extirpation of AVMs. In our institutional series, there were no instances of periprocedural complication or need for immediate return to the operating room for residual AVM resection. This represents the largest known such series of pediatric AVMs and associated intraoperative angiographic experience.