Anesthetic Management of Pediatric Extracranial Scalp Arteriovenous Malformation (AVM) : A Case-Based Review with Perioperative Management Algorithm

Introduction

Extracranial scalp AVMs are rare high-flow vascular shunts.
Can cause massive blood loss & high-output cardiac stress.
Steal phenomenon reversal: Sudden AV shunt removal → ↑SVR & ↓venous return → ↓BP

Case Description

10-year-old female
Progressive right post-auricular swelling for 2 years (Fig. 1)
Palpable thrill & audible bruit
PAC: METS >4 & Stable vitals; Investigations – unremarkable (Echocardiography revealed EF 61%)

AVM clinical image and CT angiogram — Fig.1: Preoperative clinical photograph & 3D CT demonstrating AVM & feeder arteries

Anesthetic Challenges

Airway & positioning	Hemodynamic instability
Massive blood loss	Hypothermia and metabolic disturbances

AVM monitoring — Fig.2: A snapshot of anesthesia monitor readings

Intraoperative Management

Postoperative Considerations

Ongoing bleeding & hemodynamic instability
Delayed cardiac effects
Adequate analgesia

Pearls	Pitfalls
Anticipate hemodynamic shift after ligation	Under-estimated blood loss
Controlled hypotension during dissection	Venous air embolism (open scalp veins)
Normothermia +/- Tranexamic acid	Aggressive hypotension

Conclusion

Pediatric Scalp AVMs behave like systemic AV shunts.
Anesthetic success depends on anticipation, monitoring & blood readiness.

Abbreviations:

AVM: Arteriovenous Malformation
HTN: Hypertension
MAC: Minimum Alveolar Concentration
TIVA: Total Intravenous Anesthesia
GA: General Anesthesia
SVR: Systemic Vascular Resistance

Reference: Shamim et.al. 2012 (JOACP)

Dr. Pooja Shrestha

Anesthesiology Resident (PGY-1) at Tribhuvan University Teaching Hospital, Institute of Medicine (TUTH, IOM). Her academic interests include perioperative medicine, regional anesthesia, and evidence-based practices in anesthesiology. She contributes scholarly articles on anesthesia to Epomedicine.