UNRUPTURED INTRACRANIAL AVMPresented bydr. Yunni Diansari

SupervisorDr. Alwi Shahab,SpS(K)

PREFACEAVM : uncommon caseUnruptured AVM 1:1000Symptoms : vary headache, seizure, progressif neurological deficit, intracranial bleeding>>>, or asymptomaticMultidisciplinary Management ~case by case

CASE REPORT IdentificationMale, 32 yoPalembangAdmitted to hospital : sept, 4th 2008

Anamnesis1 year before hospitalized Throbbing Headache, unilateral 3 month before hospitalizedheadache>>, vomitus (-), visual disturbance(-), hearing disturbance (-), seizure (-) 2 month before hospitalizedweakness in the right arm& right leg, legs are more weaker than arm, headache (+)1 month before hospitalizedweakness became worse, Assymetry face, disarthry

HistoryHypertension (-)Head Injury 3 years agoSeizures (-)

First time

Physical ExaminationGeneral StatusSens : compos mentis , GCS : 15BP: 120/80 mmHgPulse : 72x/mRR : 22x/mT: 36,80C

Neurological Status

Nn. CranialesN II : Visus OD 6/6, OS 6/6, edema papil(-)N VII : right paresis; assimetry face, lagophthalmus (-), N XII : tongue deviate to the right, disartry (+), athropy papil (-), fasiculation (-)

Motoric Function

Head CT Scan without contrast(20-6-08) Intracerebral SOL in left temporoparietal lobes ~susp oligodendroglioma +bleeding intraventricle

Head CT Scan with contrast (25-6-08)Radiologist suspected hemangioma appearance in left temporoparietal lobes DD: A-V malformation

CD : Right hemiparesis spastic type Right paresis N VII&XII central type

TD : Temporoparietal lobes, left hemisferium cerebri

ED :- SOL - Intracranial AVM

TherapyIVFD RL gtt xx/mInj Dexametason 3x2 amp ivInj Ranitidin 2x1 amp ivMefenamic Acid 3x500mgChest X-RayECGLab

PrognosisQuo ad Vitam : Dubia ad malam

Quo ad functionam : Dubia ad malam

Follow upSept 5th 2008Comp : headacheGeneral Status sens : cm BP:120/80, P:72x/m, RR:20x/m, T:afebrisNeurological status: stqaNeurological diagnosis : idemTherapy : continued planning for Head MRI & Head MRA

Supporting ExaminationLaboratorium Routin blood count : within normal value Chemistry clinic blood count : within normal valueChest X-Ray : normal

Sept 6th 2008 Sept 9th 2008Comp : headache

Narrowed of Left ventricle. Both of left fissura sylvii & cysterna obliterated. There is midline shift to the right. Differentiation of alba substantia&gricea are good. Pons ,Cerebellum, & paranasalis sinus are normal AVM in left temporoparietal lobesCD: right hemiparesis spastic type right paresis N VII&XII sentra typeTD: temporoparietal lobes, left cerebral hemisferium ED:Intracranial AVM

Head MRI (8-9-08)

Head MRI with contras

TherapyContinuedConsult to neurosurgery

Sept 10th 2008Comp : headache (-)General status Vital sign: within normal rangeNeurological status Motoric : strength of arm 5/5strength of leg 4/5

Neurological Diagnosis : idem

Therapy

IVFD RL gtt xx/mInj dexametason 3x1amp ivOmeprazol 1x1 tabPatient discharged from the hospital by family request

Oct 6th 2008Comp : (-)Vital sign : within normal rangeNeurological Status Nn Craniales : right paresis N VII sentral type Motoric fc : paresis (-),phys ref n/n, Pat ref -/-MRA : AVM in left hemispherium, location could be in M1 segmenPatient was suggested to reffer to Jakarta

Head MRA (20-9-08)

Dec 10th 2008Comp : headache, right visual field cutVital sign : within normal rangeNeurological status N II : right homonymous hemianopiaTherapy conservative symptomatic consult to eye departement for camfimetry (havent been done)

LITERATURE REVIEWEpidemiologyThe Incidence & Prevalence not exactly knownUSA : 0,14% symptoms 12 %Most common : 20-40 yearsMale ~ femaleAVM 2% of all stroke 38% of intracerebral hemorrhage

Definition abnormalities of intracranial vessels that constitute a fistulous connection between the arterial and venous system and that lack of a normal intervenning capillary bed.

Patological featuresAVM consist of :NidusFeeding arteryDraining vein

Types of AVM

True arteriovenous malformationCryptic AVM or Cavernous malformationVenous malformationCapillary telangiectasia/ hemangiomaDural fistule

Clinical symptoms

depend on type & location of AVM40-60% intracranial hemorrhageSeizuresHeadacheProgressif neurological deficit

most common intracranial AVM assimptomatic until the bleeding occur

Supporting examination

CT ScanMRI/MRAAngiography

Grading system

Management

GoalsLimited bleedingControl of seizureRemove the AVM ( if possible)MethodsConservativeSurgeryRadiosurgeryEndovascular Embolization

CASE ANALYSIS AnamnesisChronic throbbing headache, unilateral,Progresiff neurological deficit weakness of arm&leg, assymetry face, disartry CD: right hemiparesis spastic type right paresis N VII&XII sentral type ED : SOL AVM

Supporting examination

Head CT scan: Suspected SOLHead CT Scan with contrastAVM, DD: hemangiomaHead MRI : AVMMRA : AVM, M1 segmentLab : within normal range evaluation for surgery

It should be done Angiography grading Management & prognosis

Management case by case

Surgical Intervention angiography gradingConservative This patient angiography havent been done

Supporting examination giant AVM

Giant AVM

surgery high risk, complication >>Radiosurgery not recommendedembolization - combined therapy (presurgical & pre radiosurgery - palliative therapy Goals - presurgical limited bleeding during surgery - Preradiosurgery reduce the nidus size - Paliative decreasing blood flow to AVM decreasing neurologic deficit Conservative risk & benefit

This patient conservativeProgressif neurological deficit Vasogenic edema improvement after giving dexametasonVascular steal ischemic around brain

This patient was suggested to reffer to Jakarta endovascular embolization

Prognosis

dubia ad malamSize : giantProgressif neurological deficit

counselling important

CONCLUSIONAVM: vascular malformation >>>Grading system: therapy & prognosisManagement : case by case risk & benefitThe succesfull treatment Multidiscipline team : neurologist, neurosurgery, neuroradiologist, radiotherapist

This case reported the patient with progressif neurological deficit caused by intracranial AVM Supporting examination gave a picture of unruptured intracranial AVM Management conservative (limitation of equipment)

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