# Intraoperative neurophysiological monitoring in pediatric vascular neurosurgery: a review of the literature and institutional case series

## TL;DR

This paper reviews the limited literature on using intraoperative neurophysiological monitoring in pediatric vascular neurosurgery and shares an institutional case series showing its potential benefits.

## Contribution

The paper provides one of the few institutional case series on IONM in pediatric vascular neurosurgery, highlighting its technical feasibility and utility.

## Key findings

- IONM was useful for detecting ischemia and guiding subcortical dissection in pediatric vascular cases.
- The institutional series showed IONM enhanced safety during AVM and cavernoma surgeries.
- IONM supported functional preservation by identifying eloquent pathways and safe entry zones.

## Abstract

Intraoperative neurophysiological monitoring (IONM) has become an essential tool in neurosurgery, yet its application in pediatric cerebrovascular pathology remains scarcely documented. This paper aims to evaluate current evidence regarding the use of IONM in pediatric vascular neurosurgery and to present an institutional experience with AVM and cavernoma surgery performed with intraoperative neuromonitoring.

A scoping review of literature was conducted and a 13-year retrospective pediatric institutional case series was reported, including 8 AVMs and 4 cavernomas operated with IONM.

Only five studies met the inclusion criteria, mostly consisting of case reports or small series, confirming the paucity of literature in this field. Reported experiences consistently described IONM as useful for detecting ischemia, guiding subcortical dissection, identifying safe brainstem or cortical entry zones, and supporting functional preservation. In the institutional series, IONM enhanced surgical resection safety by guiding temporary clipping in AVMs, facilitating identification of eloquent pathways during nidus dissection, and assisting in cortico-subcortical mapping in cavernoma surgery.

Despite limited published evidence, our institutional experience supports the value of IONM as a technically feasible and potentially useful adjunct in pediatric vascular neurosurgery. For these malformations characterized by a high degree of surgical complexity, intraoperative neuromonitoring may further expand the armamentarium available to surgeons.

The online version contains supplementary material available at 10.1007/s00381-026-07228-6.