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Contributor:
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Dr. Chris Ekong
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Consultants:
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Dr. Mike Tymianski
Dr. Gary Ferguson
Dr. Christopher Wallace
Dr. J Max Findlay
Dr. R Willinsky
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Age: 29
Sex: Female
History: Sudden headaches and loss of consciousness. Examination showed GCS of 13. She moved all limbs well. Left cerebellar alaxia.
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Showed no abnormality.
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External ventricular drain on day of admission, followed 5 days later with V-P shunt. Patient fully awake on day 5. Where do we go from here?
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Options:
- Surgery for haematoma and AVM?
- Embolization, followed by surgery if indicated
- Embolization, followed by radiosurgery if indicated
- Other
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Dear Mike, Mike T., Bob, Chris, Max and Walter:
I have a 29-year-old lady who presented a week ago with cerebellar hematoma due to an AVM. The hematoma was also causing acute hydrocephalus. She has had a VP shunt and is now a Glasgow score of 15. The AVM looks like it could benefit from embolization prior to stereotaxic radiation or surgical intervention. Your opinion would be greatly appreciated. The history and images are located at:
http://www.medi-fax.com
Click on Cerebral aneurysms and other vascular malformation
Click on Case # 14
I would be happy to send the patient away at short notice.
Thank you.
Yours sincerely,
Chris
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Chris:
Looks from the CT and History that she is tolerating her clot well. In this scenario, our group usually allows the patient to recuperate, and plan another angio once the hematoma is resorbed. Yearly risk of hemorrhage remains 3-4% per year regardless of the fact that the patient bled. The advantages of this approach are that once the hematoma is resorbed, the angio may better reflect the angioarchitecture, facilitating treatment planning. Surgery is cleaner, radiosurgery planning is easier, and knowing the true angioarchitecture faclilitates embolization. We have reviewed 40 consecutive patients with AVM hemorrhage to see whether the "waiting" approach is OK. 1 re-hemorrhaged, with no clinical consequences. No other problems.
Obviously, if the patient deteriorates, she should be treated immediately. We would be happy to see the patient for consideration of embo, rads, surgery, or a combination at any time.
Best,
Mike Tymianski
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Interesting case Chris,
From this interventionalist's point of view, I would agree with Mike's earlier comments that waiting to proceed to a next step, likely carries a relatively low risk and certain advantages, primarily related to resolution of mass effect.
Before agreeing to embolize, I would want to know the surgeon's and/or radiosurgeon's estimate of risk for treatment without embolization, in case either carried a sufficiently low risk to negate the anticipated net benefit on non-definitive (adjunctive) embolization.
On the other hand, this may be a rare example of a cerebral AVM, which might be cured by embolization alone. Attempted definitive endovascular treatment, with either acrylic cement or a sclerogenic agent such as ETOH would, if incomplete, almost certainly leave a small nidus for targeting with radiosurgery. Alternatively, presurgical embolization with coils, in my experience, caries a significantly lower risk of complication, compared to liquid embolic agents, and might provide a combined risk lower than surgery alone.
The critical imperative, in my opinion, must be an assessment of the aggregate risk, if multiple therapies are contemplated, to determine and justify the cumulative risk of such a strategy.
Robert D. G. Ferguson M.D.
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Chris;
I agree with others.
Wait if he tolerates clot. Delayed MR for precise identification of nidus and related anatomy. Likely the AVM a little larger than currently demonstrated because of the clot. Nidus not that well defined on angio, and so MR in a delayed fashion will assist. No obvious angiographic ectasias to suggest waiting is not safe.
Likely surgery the most efficient way to obliterate the future risk of bleeding.
Chris
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Dear Chris,
Thanks for the chance to review this patient. Of course it could be done a number of ways, but it does look like a relatively straightforward and relatively small AVM, accessible, and while the patient is doing very well, there is a significant mass lesion in the posterior fossa. To tell you the truth, I would myself just take it out. I certainly would NOT suggest radiotherapy.
Hope you are well.
Max
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Dear Chris,
I agree with Mike and Chris that delayed imaging with angio and MR will help plan treatment. Embolization for cure may be a possibility if there is only 1 dominant feeder (PICA). Embolization as a pre-operative treatment would only be done if the surgeon felt that the endovascular treatment was important in reducing surgical morbidity.
With best regards,
Bob
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VP shunt was done 1 week ago. GCS 15. Patient up and about. Post V-P Shunt CT shows no hydrocephalus and haemetoma resolving . For follow up angiogram in 2 days.
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Angiogram attempted. Severe spasm of left vertebral artery. Procedure abandoned. Patient fine.
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Suboccipital craniotomy & excision of large AVM done. Feeding and exiting vessels coagulated & large AVM excised. Patient neurologically intact.
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Post-op MRA done. Shows no AVM.
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Chris:
Thanks for update. I would be interested in how many people would use MRA as sole post-op study. I would not, deflecting to formal angio as last definitive study. Sounds like pt is great. Well done. Significant lesion.
Chris
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Hi Chris
Well done, and good for the patient. I agree with Wallace, that one final intra-arterial angio would be a reasonable thing to pursue, as MRA can miss small lesions. We have no experience with MRA for AVMs post resection, and would therefore be weary of it on our end.
Best
Mike Tymianski
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Dear Neil,
As you know, we have both been concerned about doing an angiogram on the above patient because of the difficulty that we had during a previous angiogram. It appears that the consensus is that we cannot determine with certainty, using MRA, that the AVM has indeed been obliterated. Would you consider doing a post op angiogram under these conditions?
Chris
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Post-op angiogram done. Right vertebral was indeed occluded after pre-op angiogram.
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Comparison of left pre-op and post-op vertebral angiogram (lat)
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After a good discussion with the patient, puncture was made through right groin. Angio was primarily confined to multiple long injections in left vertebral artery. We were able to get good visualization of posterior fossa circulation including partial filling of right vertebral artery.
On comparing with previous pre-operative studies, there appears to be quite good result as no actual AV malformation now is identified although a tortuous artery is still seen in this region. Overall, procedure went quite well and patient had no untoward effects.
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