Left Frontal AVM

Contributor:

Dr. Chris Ekong

Consultants:

Dr. R Willinsky
Dr. Cameron McDougall
Dr. May Tsao
Dr. Mike Tymianski
Dr. Renn Holness
Dr. Michael Schwartz

Case 16

Age: 67

Sex: Female

History: August 7, 2002 Sudden Severe headache. Examination showed GCS of 14 but no lateralizing signs. Clinical impression: SAH. CT head and Angiogram done.

August 11 - external Ventricular drain inserted. GCS returned to 15.

August 20: External drain clamped and succesfully removed. Patient fully alert. Discharged a few days later.

October 25, 2002. Patient reviewed in office. No symptoms.

Questions:

Now what?

Nothing?

Radiosurgery?

Embolization?

Embolization + Radiosurgery?

Embolization + Surgery?

Surgery???

Dr. Chris Ekong, Neurosurgeon, Regina

TO: NEUROVASCULAR ROUNDS GROUP October 29, 2002

Dear Mike, Mike T., May, Fred, Max, Chris, Cameron, Sue, etc.:

This 67-year-old lady presented with a left frontal AVM that recently bled. She is now neurologically intact. Your opinion about further management would be greatly appreciated. Thank you.

Yours sincerely,

Chris

Dr. May Tsao, Neurooncologist, Toronto - October 30, 2002

The AVM nidus looks "largish". How large is the nidus?

May

Dr. Robert A. Willinsky, Neuroradiologist, Toronto October 30, 2002

Dear Chris,

This is a left basal ganglia AVM (Spetzler grade IV, 2+1+1). The supply is

from multiple lenticulostriate arteries. Her bleed is intraventricular and

therefore likely from the venous side. There are no obvious aneurysms.

I would suggest that no treatment is the best option. Embolization will not

be able to achieve the size reduction needed for radiation. From our data

embolization alone does not alter the natural history of bleeding.

In her age group, it would be unlikely that any treatment would compare

favourably to the the natural history even if the AVM was considered

"treatable".

Fortunately, she has made a complete recovery.

Sincerely,

Bob

Dr. Cameron McDougall, Interventional Neuroradiologist, Toronto - October 30, 2002

Chris:

I think Dr. Willinski's comments are exactly on target.

regards,

Cameron

Dr. Chris Wallace, Neurosurgeon, Toronto October 30, 2002

Agreed. No treatment/intervention

At her age, we should be happy that she has recovered.

Chris

Dr. Mike Tymianski, Neurosurgeon, Toronto - October 30, 2002

Agree with Wallace & Willinsky.

Mike Tymianski

Dr. Renn Holness, Neurosurgeon, Halifax - October 30, 2002

Hi Bob,

I dont agree with you ;What would be your response if she were 35?or

50?---age by itself can not be the deciding factor .....67 is not

"old"! Her risk of rebleeding is significant.

An MRI would give a better idea of nidus size and even if requiring more than 1

field or/and more than 1 session. Radiosurgery would be a reasonable option here.

This is what I would prefer if I were the patient because I think there is a 30-50% chance of

obliteration compared to doing nothing. I'd take the risk.

What do Mike S and Doug K think?

Renn

Dr. Michael Schwartz, Neurosurgeon, Toronto: November 1, 2002

I agree with everybody. The lesion is too large for stereotaxic radiosurgery. It has no dominant feeders that would permit embolization, and is not amenable to surgical excision. I suggest expectant treatment only. One might consider proton beam irradiation, although my limited experience with it (a very few patients referred to U.S) has not impressed me with its efficacy.

Mike S

SUMMARY

Dr. Chris Ekong, Neurosurgeon, Regina: November 3, 2002.

A 67 year old lady presented in August 2002 with an intraventricular bleed. She had minimal deficit initially but recovered completely. Cerebral angiogram revealed a large, deep, left frontal AVM with no prominent feeders. A large majority of experts felt that the best result would be achieved by conservative treatment.

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