Management of pediatric brain arteriovenous malformations in hybrid operating room: treatment allocation, intraoperative angiographic findings, and functional outcomes.

OBJECTIVE: Evidence regarding hybrid operating room-based treatment for pediatric brain arteriovenous malformations (bAVMs) remains limited. This study describes treatment allocation, intraoperative angiographic findings, and functional outcomes in a selected single-center cohort of pediatric bAVMs treated within a hybrid operating room workflow, with exploratory comparisons between low- and high-grade lesions. METHODS: Consecutive pediatric patients (<18 years) with bAVMs who were selected for curative microsurgical resection in the hybrid operating room between December 2019 and June 2025 were prospectively recorded in an institutional database and retrospectively analyzed. The cohort included patients treated with microsurgical resection alone and those treated with embolization followed by microsurgical resection during the same operative session. Lesions were categorized as low-grade or high-grade according to the Spetzler-Martin grading system and the modified classification of Grade III lesions. Perioperative variables, intraoperative angiographic findings, postoperative complications, and functional outcomes were assessed. Favorable outcome was defined as modified Rankin Scale (mRS) ≤ 2 and Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds) ≥ 6. RESULTS: Fifty-three patients were included, comprising 34 (64.2%) low-grade and 19 (35.8%) high-grade lesions. Combined embolization and microsurgical resection was performed more frequently in high-grade lesions (p < 0.001). Intraoperative angiography detected residual nidus in 6 patients (4 low-grade and 2 high-grade), all of which were resected during the same procedure, and complete obliteration was ultimately confirmed by intraoperative DSA in all patients. Postoperative complications were generally minor, with most resolving or improving substantially during follow-up. Functional outcomes at discharge and follow-up were favorable and comparable between groups, and all patients achieved mRS ≤ 2 and GOS-E Peds ≥ 6 at final assessment. CONCLUSIONS: In selected pediatric bAVMs treated within a hybrid operating room workflow, intraoperative angiography enabled real-time identification and same-session correction of residual nidus, with complete intraoperative obliteration confirmed in all patients. Favorable functional outcomes were observed in both low- and high-grade lesions. The findings are descriptive and do not allow comparison with conventional microsurgery, staged treatment, or radiosurgery due to the absence of a control group.