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How to manage arterio-venous malformation (AVM) in a child?

Q: My son is 5 years old. He became unconscious due to a sudden stroke at night this month. The CT scan and MRI reports suggest arterio-venous malformation (AVM). He was hospitalised for 9 days and now he is okay & seems normal. As per the doctor one more CT scan is required after 6 weeks. The bleeding has caused a clotting in the left side of the brain. Due to this they want to wait for 6 weeks. Presently they told us to give him Epsolin 100 mg - twice daily. What should I do? What is the treatment? Is waiting the best decision or should we take a second opinion? Is there any threat to his life during these 6 weeks? What are the chances of bleeding again? As per doctors it is too risky to operate, as he is just 5 years old; is it true? Is paralysis or mental problem possible during treatment? Which is the best place & best doctor in India for the treatment of the same? What will be the cost?

A:AVMs of the brain are a bunch of tangled abnormal blood vessels which may create problems in the following ways: bleeding, a progressive loss of focal neurological function, stroke like episodes due to clotting in the blood vessels, convulsions or headaches. The risk after an initial bleeding, is of a rebleed. The risk is 2-4% per year (meaning that 2-4 patients amongst 100 will bleed) and the cumulative risk approaches 25% by 5 years. The younger the patient, more the risk. Treatment could include any of the following modalities: 1. Surgical, whereby the skull is opened, the abnormal vessels identified, clipped and excised. 2. Stereotactic radiotherapy, whereby the blood vessels get blocked over 1-2 years and thus there is no risk for bleeding. 3. Selective embolisation of the blood vessels, whereby a glue like substance is injected during selective angiogram so as to block the abnormal vessels. In expert hands, the risk of morbidity and mortality is 0-2% which is rather good. But the course of treatment will depend upon variables like: size and location (whether in a critical site or deep situation). Thus before any treatment an angiogram is mandatory to define the type of AVM and the nature of abnormal blood vessels. There are a number of centres equipped to do this treatment. Some neurosurgeons have special expertise in this. I am unaware of the city where you reside and your neurosurgeon should be able to guide you. In Delhi, Sir Ganga Ram Hospital; Max Speciality Hospital and AIIMS are competent.

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