• HPI: 22 y.o. male has been healthy until two days prior when he had left foot weakness with dizziness and nausea while wrestling that resolved in 20 minutes, followed two days later by severe difficulty with left arm and leg strength, to the point he could not walk during lifting weights after doing stomach exercises. No other complaints except for headache. Has been otherwise healthy, uses tobacco daily, social alcohol consumption on the weekends, no recreational drugs. 

    PMH: Otherwise Healthy Male 

    Family History: Unremarkable. 

    Neurologic: Awake and oriented x 3, no cranial nerve abnormality , L sided weakness worse in the lower extremities, sensations intact to light touch, exaggerated reflexes on the left knee and ankle jerks. Positive Babiniski on the left sides.

     

    Figure 1. Axial non contrasted CT Head showing a right frontal-parietal para-median hematoma

    Figure 2. Diagnostic internal carotid artery angiogram showing a large AVM with a large central draining vein

    Figure 3. T2 Weighted images of an MRI showing a right peri-central AVM.

    1. How would you Grade this AVM according to Spetzler-Martin grading?

    2. What would be the plan for managing this patient?

    3. In case a combination of modalities are chosen, what form of combination would you choose?

    4. What other imaging would you obtain in case surgical resection is contemplated?

     5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:

    • I'd like to see the venous phase angiogram. I think that the stroke promotes a natural dissection of the AVM nidus from normal cerebral tissue wich makes surgery reasonable and easier. If there aren't previous deficits I'd consider and discuss other options instead surgery.
    • I would get fMRI (motor) and tractography
    • Though it is located in an eloquent area, it is on the right side, and the problem is focused on the preservation of pyramidal tract. As this is a hemorrhagic case, I would recommend surgical resection first. About combination therapy, as this type of AVMs are fed by MCA and ACA, it is not so difficult to control the feeder flow.
    • It is difficult but resectable lesion provided that fMRI does show that the motor area is exactly represented by the MRI image of the lesion's core (which is quite unlikely). Preop embolization would be helpful in reducing the lesion vascularity-size, and also in showing any possible increase in neurological defect while closing temporarilry any specific vessels provided adequate microcatheters are used (which means that this should be a very wisely-conducted procedure to be done by experienced hands!). I had some experience of such cases, and i sent two of them for postop radiosurgery following detection of little residuals fed by deep, small feeders, but those cases had been operated on without previous embolization. One of them developed a long-term-postop deficit due to radiation injury.
    • keeping in view the size, location and age of patient, best mode of treatment is GKS.
    • In question number 4, I would do fMRI for both speech and motor.
    • The selected angiographic images are insufficient to adequately grade this AVM. In addition, it would be nice to be better able to characterize the angioarchitecture of this AVM, looking for intranidal aneurysms, pedicle aneurysms, or the presence of direct fistulae. These findings may make the latency associated with radiosurgery less favorable.
    • tough case, but superficial and apparently with superficial drainage. young patient, big bleed. I would be inclined to be more aggressive than with deep lesion, even given eloquent location. fMRI would really help here in decision-making. Great case to discuss!
    • your history did not mention whether he is right handed or left handed, to determine the dominant side of brain and plan monitoring during surgery.
    • Hard to make conclusion for treatment without full angio views and run. Superselective angio may also be helpful to figure out where central artery is located. Id probably radiate based on above images. Best chance of motor recovery is to do nothing then radiosurgery
    • in my feasibility/availability situation, I prefer the patient undergo embolization in the first step and then look at the angio- status in a short while , then decide whether to intervene surgically?, go for radisurgery? or wait & watch!
    • Thank you
    • It is difficult to give an exact S-M grade. This is because there is no ruler on the given axial MRI images. Thus it is hard to say if the size is just under 3 cm, or just over 3 cm, which would influence the S-M grade.
    • Venous drainage is not shown so deep drainage assumed for grading purposes.
    • This AVM has bled. A combination therapy of embolization followed by surgical excision is the best therapy as it cures the patient and obviates risk of re-hemorrhage. fMRI motor will help in assessing the exact relation to the sensory motor strip. Intraoperative cortical stimulation will help in preserving motor strip. The hematoma will aid to certain extent in dissecting the AVM.
    • The Southern General Hospital in Puebla , Mexico where I work has the means to perform MAV embolization but the patients can not afford it so I would operate this patient without its benefit, under sontrolled hypotension.
    • Im a medical student.

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