Hematoma intraparenquimatoso como inicio de una malformación arteriovenosa. Reporte de un caso / Intraparenchymal Hematoma as the Beginning of an Arteriovenous Malformation. Case Report

RESUMEN Las malformaciones arteriovenosas cerebrales son anormalidades vasculares caracterizadas por una conexión fistulosa entre arterias y venas sin la intervención del lecho capilar normalmente existente. Se localizan con frecuencia en el territorio de las grandes arterias cerebrales, pero pueden aparecer en cualquier otro lecho vascular y son las causantes de hemorragias intracerebrales, epilepsia, signos neurológicos focales y otros síntomas. Se reporta el caso de una paciente de sexo femenino, de 64 años, hipertensa y diabética, que de forma aguda presenta cuadro de debilidad hemicorporal izquierda. Al examen físico presentaba, disartria, hemiparesia izquierda y signos meníngeos. La tomografía axial computarizada inicial mostró un hematoma intraparenquimatoso parietooccipital derecho con apertura al sistema ventricular. La angio-TAC mostró malformaciones arteriovenosas cerebrales parietooccipitales derechas. El tratamiento de este padecimiento depende de los factores del paciente, así como de factores angiográficos. Las diferentes opciones son: conducta expectante, tratamiento médico sintomático, resección quirúrgica, terapia endovascular, radiocirugía estereotáxica. Se presenta el caso clínico de un hematoma intraparenquimatoso secundario a una malformación arteriovenosa cerebral porque es un padecimiento poco frecuente en un adulto mayor.

ABSTRACT Cerebral arteriovenous malformations are vascular abnormalities characterized by a fistulous connection between arteries and veins without the intervention of the normally existing capillary bed. They are frequently located in the territory of the great cerebral arteries, but they can appear in any other vascular bed and are causes of intracerebral hemorrhages, epilepsy, focal neurological signs, and other symptoms. A case of a 64-year-old female patient, hypertensive and diabetic, who acutely presented with left hemicorporal weakness, is presented. On physical examination, she had dysarthria, left hemiparesis and meningeal signs. The initial computed tomography scan showed a right parietooccipital intraparenchymal hematoma opening to the ventricular system. CT angiography showed right parietooccipital cerebral arteriovenous malformations. Treatment of this condition depends on patient factors, as well as angiographic factors. The different options are: watchful waiting, symptomatic medical treatment, surgical resection, endovascular therapy, stereotaxic radiosurgery. The clinical case of an intraparenchymal hematoma secondary to a cerebral arteriovenous malformation is presented because it is a rare condition in an older adult.

Remisión de aneurisma luego de exéresis de MAV con aparición de síndrome del acento extranjero / Aneurysm remission after MAV surgery with appearance of foreign accent syndrome

Introducción: Los aneurismas asociados a malformaciones arteriovenosas (MAV) son lesiones vasculares que suelen encontrarse hasta en el 15% de los casos, incrementando el riesgo global de hemorragia. La conducta frente a los aneurismas asociados es dicotómica en la literatura, mientras existen reportes de la desaparición de los mismos luego de la exéresis de la MAV, otros artículos enfatizan su tratamiento precoz. El síndrome del acento extranjero es un raro trastorno neurológico en el que el paciente habla su lengua materna como lo haría una persona extranjera y suena con “acento” extranjero a oídos de los oyentes nativos. Objetivo: Presentar un paciente que desarrolla el síndrome del acento extranjero posterior a la exéresis de una MAV y la evolución de un aneurisma asociado. Presentación de caso: Paciente pediátrico que luego de la exéresis de una MAV fronto-opercular posterior izquierda remite por completo un aneurisma de hiperflujo asociado, presentando en el postquirúrgico el síndrome del acento extranjero.Conclusión: Queda reportado el caso de este raro síndrome y la resolución espontánea de un aneurisma proximal luego de la exéresis de una MAV.

Introduction: The aneurysms associated with arteriovenous malformations (AVM) are vascular lesions that are usually found in up to 15% of cases, increasing the overall risk of bleeding. The behavior against associated aneurysms is dichotomous while there are reports of the disappearance of the same after the removal of the AVM, other items emphasize early treatment. Foreign accent syndrome is a rare neurological disorder in which the patient speaks his mother language as you would a foreigner and sounds with foreign "accent" to native listeners.Objective: To report a patient who developed foreign accent syndrome after excision of an AVM and the evolution of an associated aneurysm.Case presentation: pediatric patient that after a resection of fronto-opercular AVM refers back completely on an aneurysm associated hyper flow, presenting postsurgical foreign accent syndrome.Conclusion: the case of this rare syndrome and spontaneous resolution of a proximal aneurysm after excision of an AVM is hereby reported.

Risk factors of intracranial hemorrhage after endovascular therapy of cerebral arteriovenous malformation embolization / 中国基层医药

Objective To study the risk factors of intracranial hemorrhage after endovascular therapy of cere-bral arteriovenous malformations embolization.Methods the clinical records and images of 230 patients with cAVMs were retrospectively reviewed.Patients with intracranial hemorrhage after endovascular therapy in 3 days were recorded and the risk factors of hemorrthage by using multivariate logistic regression for guiding the treatment strategy were studied.Results There were 15 patients occurred intracerebral hemorrhages.After treatment the area of cAVMs was significantly smaller than that before treatment[(2.18 ±0.91)cm vs (6.67 ±1.56)cm],the difference lvas a statis-tically significant (t =9.627,P <0.05).A partial AVM reduction of ≥36.5%(P =0.031)and hypertension(P =0.025)were considered as risk factors for hemorrhage after endovascular therapy of cAVWs.Conclusion Patients receives a partial AVMreduction of ≥36.5% or with hypertension history have a tendancy of increasing hemorrhage after endovascular therapy of cAVMs.It's helpful for preventing intracerebral hemorrhage if the arterial blood pressure maintains after endovascular therapy.

Basic and clinic study of the density proportion in forming AVM embolic agent-NBCA mixed liquid / 介入放射学杂志

Objective By analysing the relation between the proportion of NBCA and the arteriovenous circulation time will give the optimal proportion of NBCA for embolizing cerebral AVM with microcatheter clinically.Methods (1) The fresh aterial blood fractions from intracranial hemorrhage in vitro of 16 cases were mixed with the 20%、33%、50%、70% and 80% NBCA respectively and evaluated the coagulation times with the different densities of NBCA in the fresh aterial blood in vitro; (2) two cases were performed with superselective embolotherapy to five feeding arteri. Results (1) the correlation index between different densities of NBCA and the fresh areterial blood in vitro , T (c) =e 1.9994-1.487D , (2) about 90% nidus of AVM were occluded after embolization, and the fistulas of AVF were basically closed after embolization.Conclusions There is a mathematical model between the arteriovenous circulation time and the proportion of NBCA, thus providing the theoretical clinical application of the embolotherapy of CAVM with microcatheter.

The image characters and endovascular embolization of cerebral arteriovenous malformations with bleeding / 中华放射学杂志

Objective To discuss the image characters and the technical manipulation of endovascular embolization for cerebral AVM with bleeding. Methods The cerebral AVMs with bleeding in 56 cases were confirmed by CT, MRI, and whole cerebral DSA. Depended on the nidus of AVM, the superselective endovascular embolization with NBCA or embolization combined with radiological surgery was chosen. Results The nidus was eliminated for 100% in 36 cases after embolization for 1 to 3 processes. The rebleeding was found in 2 cases with new growth and survival aneurysm in nidus during the follow-up period and treatment with X-knife, and was cured by the second embolization. Conclusion The main causes of AVM bleeding included aneurysm and aneurysm-like dilation beside and located at the nidus, fine draining veins, and growth in the ventricles. To prevent the brain from bleeding, it is favourable to eliminate the aneurysm in AVM during embolization.

Multiple Cerebral Arteriovenous Malformation

Multiple cerebral arteriovenous malformations(AVMs) are thought to be rare lesions. The authors present a case of multiple AVMs in te left cerebral hemisphere. A 26-year-old male patient came to the hospital for evaluation of recurrent attacks of generalizd seizures. Cerebral angiography demonstrated two separated AVMs having different feeders and drain veins in the left cerebral hemisphere. Using staged operations we excised the lesions completely. The criteria and surgical tactics of multiple AVMs are discussed with a review of the literature.

Clinical Study on intracranial Arteriovenous Malformations: Clinical Analysis of 187 Cases

In an effort to understand the clinical symptomatology of intracranial arteriovenous malformations(AVMs), to determine their best management policy, and to accumulate our clinical data, a retrospective clinical analysis of 187 patients with intracranial AVMs which were diagnosed by neuroradiological studies or histopathologically was performed during the period from January 1983 to May 1994. Among the 187 patients of whom for patients with dural type AVM and eight referral patients were excluded, 120 patients were treated surgically and the other 55 patients, managed conservatively. The outcome of all patients were analysed and their post-ictal status was followed for an average of 31.7 months. The results were as follows. 1) The peak incidence of intracranial AVMs was in the third decade(mean age 28.9 years) followed by the second decade and the fourth decade. The male to female ration was 1.9:1. 2) The presenting symptoms were mainly intracranial hemorrhage(50.3%), seizure(33.2%) and headache(9.6%). Among the types of intracranial hemorrhage, intracerebral hematoma was the most frequent, and of the seizure type, generalized seizure was seen most frequently. 3) The locations of intracranial AVMs were hemispheric(78%), deep seated(14%), posterior fossa(6%), and dural(2%). 4) The presenting symptoms of intracraial hemorrhage and seizure depended significantly on the size of the AVM;71% of small AVMs(6cm) presented with seizure. 5) The rate of rebleeding was 21%(20 of 94) and the associated mortality rate was 5%( of 20). 6) Concomitant aneurysms were found in 14 cases(7.5%). 7) In surgically treated cases, the mortality rate was 2.5% and its morbidity rate, 26.7%. In conservatively treated cases, the mortality rate was 3.6% and its morbidity rate, 27.3%. 8) The clinical outcome of children was similar to that of adults. 9) Patients with seizures showed a better outcome than those with hemorrhages and the clinical outcome did not depend on the methods of treatments in either patients with hemorrhages or those with seizures. 10) With respect to the Spetzler-Martin grade, the surgical outcome improved ssignificantly as the grade became lower. 11) There was a marked tendency for postoperative neurological deficits to improve with time during the mean follow-up period(31.7 months). As such, early morbidity rate was 50% and late morbidity rate decreased to 26.7%. 12) Preoperative embolization was effective for a safe surgical removal of the AVMs with a poor grade. 13) Of the patients who did not have seizure before surgery, 7.9%(6/76) had late seizures in whom all were not well controlled with medication. Of the patients who had seizures before surgery, 82.9%(29/35) were either cured or controlled with medication.

COMBINATION OF SURGICAL RESECTION WITH INTRAVASCULAR EMBOLIZATION FOR TREATMENT OF GIANT CEREBRAL ARTERIOVENOUS MALFORMATIONS / 解放军医学杂志

To investigate the effects of preoperative intravascular embolization on treatment of intracranial giant arteriovenous malformations (AVMs), 27 patients with intracranial giant AVMs were successfully treated from August, 1997 to April 1998 every patient was treated with preoperative intravascular embolization. Compared with single surgical resection, it was found that surgical resection after intravenous embolization can greatly reduce the intraoperative hemorrhage, diminish postoperative mortality and morbidity, and prevent normal perfusion pressure breakthrough (NPPB) significantly. The present study suggested that combination of surgical resection and intravascular embolization was an effect way in the treatment of giant cerebral AVMs.