Left Temporal AVM (Pediatric)

Contributor:

Dr. Chris Ekong

Consultants:

Dr. Mike Tymianski
Dr. R Willinsky
Dr. Cameron McDougall
Dr. J Max Findlay
Dr. Michael West
Dr. Karel terBrugge
Dr. Douglas Kondziolka
Dr. Renn Holness

Case 23

Age: 9

Sex: Female

History: Seizure
Examination: Normal

Would you?

- Watch?

- Embolize?

- Do surgery?

- Radiate?

Dr. Mike Tymianski, Neurosurgeon, Toronto - June 25, 2004

Hi Chris

Had a look at the MRI's & Angios.

Tough case - Young - so wish there was something we could do easily. However, this is a large, diffuse AVM in an eloquent location, deep drainage. It is the kind that we are not keen to tackle surgically at the outset, and is too big for radiosurgery. I believe that, due to its diffuseness we might have trouble with embolization for size reduction in order to make it amenable for radiation or surgery.

I Will pass the CD on to my colleagues and have them send you comments directly.

I had a hard time navigating through some of the angios. The one thing that we'd like to exclude with a young person are high risk features in the AVM (intranidal aneurysms etc...). I'll ask Karel and Bob to have a close look, but we may need better images, and possibly a super-slective angio in this young lady.

Best,

Mike T

Dr. Robert Willinsky, Neuroradiologist, Toronto - June 25, 2004

Chris,

I agree with Mike. I believe embo for size reduction is not feasible. I would consider superselectives if the patient had bled. Otherwise I support no treatment.

Best regards,

Bob

Dr. Cameron McDougall, Neurosurgeon, Phoenix - June 28,2004

Chris:

I think Mike and Bob are right on target (as usual).

Cameron

Dr. Renn Holness, Neurosurgeon, Halifax - June 28, 2004

Chris:

I think Doug K's work suggests a " risk for bleeding " of > 80% over the next 40-50yrs in this sort of case. I am also concerned about the unknown effects of "steal"& seizures which may well worsen with the passage of time .If this were my kid (or grandchild!) I'd want something more definite done.

I'd therefore vote, for starters, to do what Mike T. 1st suggested

i.e. repeat angio with selective studies (incl. external runs)

(with a view to considering aggressive embo in several sessions. If necessary, then Sx or RadioSx. The latter as we know, has been shown to reduce Sx frequency & severity).

I'd also be interested in Ian's opinion.

Renn

Dr. Chris Ekong, Neurosurgeon, Regina - June 28, 2004

Thanks Renn:

I'll ask Ian and Doug.

Chris

Dr. Chris Ekong, Neurosurgeon, Regina - June 28,2004

Dear Doug, Kotoo, and Ian:

What would you offer this 9 year old who presented with seizures?

NB: Please note Renn's Comments .

Regards,

Chris

Dr. Douglas Kondziolka, Neurosurgeon, Pittsburgh - June 29, 2004

Chris,

I would manage the seizures medically. If the child has a hemorrhage, then staged volume radiosurgery could be considered. Without a prior bleed, I would observe for now.

Doug

Dr. Karel terBrugge, Neuroradiologist, Toronto - July 5, 2004

Dear Chris,

Thank you for asking me to comment on theMRI and angiographic findings on this 9-year old girl. I am not certain about the clinical presentation but I could imagine it might be a seizure onset. This type of vascular lesion tends to present in children with seizures and in our opinion does not represent a true anteriovenous malformation. The changes are induced partially by ischemia and the diffuse nidus and shunting may be in part related to ischemia. As the MRI indicates there is normal brain in between abnormal vessels which is of course unheard of in classic AVMs. Because of this aspect no surgical or stereotacic radiosurgical treatment can be proposed and embolization is also contra indicated. These patients tend to remain stable for a long time but at some point will start to present with bleeding episodes which will then lead to a negative outcome.

Thank you for asking me in consultation with respect to the angiographic findings on this patient.

Best personal regards,

Karel

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