Pediatric Vascular Neurosurgery and Intraoperative Neuromonitoring: Clinical Evidence and Surgical Experience

Intraoperative neuromonitoring (IONM) has quickly become a valuable tool in adult neurosurgery for its ability to provide real‑time insight into functional pathway integrity during high‑risk procedures.

In pediatric vascular neurosurgery, that role may be even more consequential.

A recent review and institutional case series by Galeazzi et al. (2026) offers an important perspective on how IONM is being applied in children undergoing surgery for arteriovenous malformations (AVMs) and cavernous malformations, and why its use continues to expand in these technically demanding cases.¹

At Neuromonitoring Associates (NMA), this aligns closely with what we observe in practice: when neurological risk is high and margins are narrow, objective, real‑time neurophysiological data meaningfully supports patient safety.

Pediatric Vascular Neurosurgery: High Complexity, High Stakes

Pediatric cerebrovascular lesions are uncommon, but their impact is significant. AVMs in children account for approximately half of all spontaneous intracranial hemorrhages in this population and are often associated with higher rupture and recurrence rates compared to adults.¹ Cavernous malformations, particularly those involving the brainstem, also tend to behave more aggressively in pediatric patients, with hemorrhage leading to acute neurological decline.¹

Surgical intervention is frequently necessary—and often urgent. These procedures routinely involve:

• Eloquent cortex
• Deep subcortical motor and sensory pathways
• Brainstem nuclei and cranial nerve fibers

In these settings, anatomical guidance alone cannot account for the functional consequences of dissection, vessel occlusion, or retraction. IONM helps bridge that gap by translating anatomy into physiology in real time.

How IONM Helps Pediatric Vascular Neurosurgery

In their structured review, Galeazzi and colleagues identified a small number of published studies specifically addressing IONM in pediatric vascular neurosurgery.¹ While the volume of literature is limited, the reported experiences are notably consistent in their conclusions.

Across published series and case reports, IONM was described as:

• Helpful in detecting ischemic changes
• Valuable during subcortical and deep dissection
• Effective in identifying safe cortical or brainstem entry zones
• Supportive of functional preservation during resection¹

Importantly, these findings mirror the authors’ own institutional experience and reinforce a growing consensus: the available evidence trends strongly toward clinical utility rather than uncertainty.

A 13‑Year Institutional Case Series

To complement the broader literature, Galeazzi et al. reported a 13‑year retrospective case series involving 12 pediatric patients—8 AVMs and 4 cavernous malformations—managed surgically with multimodal IONM.¹

Monitoring strategies included combinations of:

• Motor evoked potentials (MEPs)
• Somatosensory evoked potentials (SSEPs)
• Visual evoked potentials (VEPs)
• EEG
• Cortical and subcortical mapping¹

Several practical themes emerged:

• During AVM surgery, IONM guided temporary arterial clipping, allowing surgeons to assess functional tolerance to vascular occlusion in real time
• Subcortical stimulation assisted with tract identification and preservation during deep dissection
• In cavernoma cases—particularly those involving eloquent cortex or the brainstem—mapping helped define safe entry points while minimizing neurological risk¹

While the authors appropriately note the absence of a control cohort, the intraoperative value of continuous functional feedback was repeatedly demonstrated across lesion types.

Pediatric-Specific Challenges—and Why Monitoring Still Matters

Neuromonitoring in children presents well‑recognized technical challenges. Immature neural pathways, higher stimulation thresholds, smaller anatomical dimensions, and sensitivity to anesthetic agents can all affect signal reliability.¹

Yet these challenges highlight the importance of monitoring.

As Galeazzi et al. emphasize, IONM remains the only intraoperative modality capable of assessing functional integrity in real time.¹ Imaging and navigation systems provide essential anatomical context, but they cannot detect evolving functional compromise during vessel occlusion or tissue manipulation.

In pediatric patients, where neurological injury carries lifelong consequences, that distinction matters.

Key Takeaways for Surgical Teams

1. IONM is feasible in pediatric vascular neurosurgery - With experienced teams and appropriate protocols, reliable monitoring can be achieved even in young patients.¹

2. Functional preservation is a consistent theme - Across AVMs and cavernomas, IONM helped guide safer dissection and entry‑zone selection.¹

3. Multimodal strategies provide the most actionable insight -Combining monitoring and mapping techniques enhanced intraoperative decision‑making.¹

4. Existing evidence trends clearly toward benefit - Published experiences and institutional data consistently describe IONM as a valuable adjunct.¹

5. Pediatric patients stand to gain significantly - When lifelong neurological outcomes are at stake, real‑time functional feedback is especially impactful.¹

6. IONM integrates seamlessly into complex surgical workflows- By guiding vessel identification, clipping and sacrifice decisions, and real‑time navigation, IONM supports safer resection while prioritizing functional preservation.

Looking Ahead

The work by Galeazzi et al. reveals that IONM plays a meaningful role in enhancing safety during complex pediatric vascular procedures. As collaborative, multi‑center efforts continue to grow, future research will further refine protocols and define best practices.

In the meantime, for high‑risk pediatric cerebrovascular surgery, IONM is a vital component of a comprehensive, patient‑centered approach—one that prioritizes both surgical success and long‑term neurological health.

Reference

¹ Galeazzi M, Montereale N, Di Domenico M, et al. Intraoperative neurophysiological monitoring in pediatric vascular neurosurgery: a review of the literature and institutional case series. Child’s Nervous System. 2026;42:131. https://doi.org/10.1007/s00381-026-07228-6