Vascular Lesions in Children

Vascular lesions are rare problems that affect the blood vessels in the brains and spinal cords of people from all ends of the age spectrum, including newborns, infants, and growing children. Although the symptoms tend to appear rather abruptly and the condition can be alarming and potentially life-threatening, many of these conditions are successfully treated by our team of physicians. The most common vascular lesions in children include aneurysms, arteriovenous malformations (AVM), cavernous malformations, and moyamoya disease. These vascular lesions have some similarities since they each involve the blood supply to the brain. Some signs of problems include headaches, seizures, or coma. In lesions where symptoms are gradual, parents often notice a slow change in a child’s function over time.

Aneurysms are rare pediatric lesions that can affect blood vessels throughout the body. In the young brain, the berry-like protrusions most commonly occur where the major arteries branch off into smaller arteries. Most aneurysms are discovered when they rupture, usually causing an intense headache. Additional symptoms include vomiting, a stiff neck, light sensitivity to the eyes, weakness, eye movement problems, stupor, seizures, and even coma and death.

Arteriovenous Malformations (AVMs) are composed of arteries that communicate directly with veins rather than feeding into progressively smaller blood vessels that would then supply the brain with nutrients. As a result, blood pouring into these veins from the arteries exerts extremely high pressure which eventually causes the veins to rupture. This leads to bleeding in the brain (hemorrhage) and also areas of the brain surrounding the AVM may not receive appropriate blood flow, potentially leading to stroke. Symptoms of AVM include seizures, headache and neurological problems involving speech, vision, strength, coordination or sensation.

Cavernous Malformations (Cavernomas) are the most common neurovascular lesion in children. These lesions are much less dangerous than AVMs because they do not have any intervening brain substance. They are just small clusters of blood vessels that rarely cause life-threatening bleeding because blood leaks very slowly, rather than rupturing. The leaking blood can irritate the area of brain surrounding the cavernous malformation and cause seizures. The downside is that they tend to be in more critical areas which makes their complete removal much riskier.

Moyamoya Disease was first described in children of Japanese descent. This condition involves the carotid arteries, which are two of the large feeding vessels to the brain. The carotid arteries undergo an unexplained but spontaneous narrowing, resulting in a stroke or evidence of insufficient blood flow to the brain. The brain responds by developing many small collateral vessels, which on X-ray images can appear to resemble a “puff of smoke,” and thus the Japanese name, moyamoya. Moyamoya has been found in the United States, Europe, Australia and Africa, primarily affecting children, adolescents, and young adults. Females are more frequently affected than males. Untreated patients develop headaches, spontaneous bleeds and strokes with progressive neurologic decline unless surgically revascularized with the blood supply being reinstated.

Diagnosing Pediatric Vascular Lesions

Once a vascular event is suspected, tests are immediately done in order for the physician to confirm the diagnosis and create an optimal treatment plan. The physician will order a CT scan and MRI/MRA of the brain and neck which help him to detect blood or stroke in the brain. More often than not, for vascular lesions, the physician will recommend a Diagnostic Cerebral Angiogram in order to take a closer look at the brain’s blood vessels. Please see Diagnostic Cerebral Angiogram section for more information on this procedure.

Treatment of Pediatric Vascular Lesions

There are three different treatment options for children with vascular lesions.

Endovascular embolization is performed by a neurointerventional radiologist. This involves treating the problem by injecting different materials in the blood vessels to help stop the source of bleeding. This may be a permanent cure, but depending on the condition, this procedure may be performed in conjunction with surgery. The purpose of doing an embolization first would be to decrease the risks of bleeding or stroke during surgery. Please see Neurointerventional Procedures for more information on the specific types of procedures.
Surgery may be appropriate for lesions that cause symptoms and are accessible. For cavernous malformations, surgery is the treatment of choice since cavernous malformations are not visible on an angiogram and consequently, endovascular embolization is not possible. In this approach, the surgeon treats the vascular lesion by removing it surgically, thereby eliminating the risk of bleeding. Please see operative procedures for more information on this procedure.
Radiosurgery is used to treat vascular lesions with a type of focused X-rays such as the gamma knife. This X-ray treatment uses radiation to selectively occlude the lesion, but unlike surgery, the treatments may require up to two years to be effective. Please see AVM section for more information on this procedure.

Recovering from Stroke

Recovering from stroke is different for each child, but generally children are able to recover more abilities than older people. Children almost always recover the use of their arms and legs and their ability to speak after a stroke. Prompt medical treatment and rehabilitation therapy can maximize recovery.

The effects of stroke in a child are generally the same as in an adult. The most common effects are:

Hemiparesis (weakness on one side of the body), or hemiplegia (paralysis on one side of the body).
One-sided neglect (unilateral neglect), which causes the stroke survivor to ignore or forget their weaker side.
Aphasia (difficulty with speech and language), or dysphagia (trouble swallowing).
Decreased field of vision and trouble with visual perception.
Loss of emotional control and changes in mood.
Cognitive changes or problems with memory, judgment and problem-solving.
Behavior changes or personality changes, improper language or actions.