Importância do diagnóstico por imagem em pacientes com sangramento uterino anormal / Importance of diagnostic imaging in patients with abnormal uterine bleeding

O sangramento uterino anormal é diagnóstico sindrômico comum no consultório do ginecologista e pode comprometer substancialmente a qualidade de vida. O objetivo no diagnóstico de sangramento uterino anormal é distinguir pacientes com causas estruturais (anatômicas), como pólipo, adenomiose, leiomioma, malignidade e hiperplasia, de pacientes que apresentam anatomia normal, nas quais o sangramento pode ser devido a alteração dos mecanismos de coagulação, distúrbios ovulatórios, distúrbios primários do endométrio, iatrogenia, ou ter outra causa não classificada. O diagnóstico se inicia a partir de anamnese detalhada e exame físico geral e ginecológico completos, seguidos da solicitação de exames complementares (laboratoriais e de imagem), conforme indicado. O exame de imagem de primeira linha para identificação das causas estruturais inclui a ultrassonografia pélvica. Histerossonografia, histeroscopia, ressonância magnética e amostragem endometrial para exame de anatomia patológica são opções que podem ser incluídas no diagnóstico a depender da necessidade. O objetivo deste artigo é apresentar a relevância dos exames de imagem na investigação das causas de sangramento uterino anormal.

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office and may substantially affect quality of life. The aim in the diagnosis of abnormal uterine bleeding is to distinguish women with anatomic causes such as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia from women with normal anatomy where the cause may be coagulopathy, ovulatory disorders, endometrial, iatrogenic and not otherwise classified. Diagnosis begins with a thorough history and physical examination followed by appropriate laboratory and imaging tests as indicated. The primary imaging test for the identification of anatomic causes include ultrasonography. Saline infusion sonohysterography, magnetic resonance, hysteroscopy, endometrial sampling are options that can be included in the diagnosis depending on the need. The aim of this article is to present the relevance of imaging exams in the investigation of the causes of abnormal uterine bleeding.

Ligadura temporal laparoscópica de arterias uterinas en un caso de vasculatura miometrial aumentada relacionada con el embarazo / Laparoscopic temporary uterine artery ligation in a case of pregnancy-related increased myometrial vasculature

Resumen ANTECEDENTES: La vasculatura miometrial aumentada es una afección poco común, con alto riesgo de hemorragia masiva. Su fisiopatología se relaciona con una remodelación inadecuada del endometrio y miometrio, posterior a un evento obstétrico. El tratamiento convencional, en caso de sangrado masivo, es la histerectomía. En la actualidad, los tratamientos con enfoque conservador que permiten el embarazo espontáneo, ofrecen una opción segura para estas pacientes. CASO CLÍNICO: Paciente de 20 años, primigesta, con deseo gestacional a futuro, llevada a la sala de urgencias debido a una hemorragia uterina profusa, con datos clínicos de bajo gasto, antecedente de aborto completo de 10 semanas de gestación un mes antes. En el ultrasonido Doppler se observó una imagen anecoica irregular en el fondo uterino que interrumpía la interfase endometrio-miometrial asociada con flujo sistólico alto. Para el control vascular se indicó cirugía conservadora de útero, con ligadura temporal laparoscópica de las arterias uterinas; además aspiración uterina. Estos procedimientos trascurrieron sin complicaciones. El reporte histopatológico del material aspirado fue de tejido trofoblástico asociado con ectasia vascular. CONCLUSIÓN: La ligadura temporal laparoscópica de las arterias uterinas es un procedimiento eficaz, en casos seleccionados, de control vascular durante la extracción del tejido trofoblástico remanente, en casos de vasculatura miometrial aumentada, relacionada con el embarazo, con recuperación completa de la irrigación uterina y preservación del útero.

Abstract BACKGROUND: Enlarged myometrial vasculature is a rare condition with a high risk of massive haemorrhage. Its pathophysiology is related to inadequate remodelling of the endometrium and myometrium following an obstetric event. The conventional treatment for massive haemorrhage is hysterectomy. Currently, conservative management approaches that allow spontaneous pregnancy offer a safe option for these patients. CLINICAL CASE: 20-year-old primigravida with future pregnancy aspirations, presented to the emergency department with heavy uterine bleeding, clinical data of low output, history of complete abortion at 10 weeks' gestation one month earlier. Doppler ultrasound showed an irregular anechoic image in the uterine fundus interrupting the endometrial-myometrial interface associated with high systolic flow. For vascular control, uterine-sparing surgery with laparoscopic temporary ligation of the uterine arteries and uterine aspiration was indicated. These procedures were performed without complications. The histopathological report of the aspirated tissue was trophoblastic tissue associated with vascular ectasia. CONCLUSION: Temporary laparoscopic ligation of the uterine arteries is an effective procedure in selected cases for vascular control during removal of the remaining trophoblastic tissue, in cases of pregnancy-related increased myometrial vasculature, with complete recovery of uterine irrigation and preservation of the uterus.

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía / Uterine arteriovenous malformation as a cause of late puerperal hemorrhage

Resumen ANTECEDENTES: Las malformaciones arteriovenosas uterinas constituyen una causa infrecuente de hemorragia puerperal, en la bibliografía solo se encontraron 150 casos. Su conocimiento es importante porque son potencialmente mortales y porque se ha registrado un aumento en los últimos años. Suelen estar relacionadas con intervenciones en el útero: legrados, cesáreas o miomectomías o asociadas con neoplasias (enfermedad trofoblástica gestacional o adenocarcinoma endometrial), aunque otras son congénitas. CASO CLÍNICO: Paciente de 32 años, con una conización cervical y ablación de un mioma uterino mediante radiofrecuencia como únicos antecedentes de interés. A los 15 días posteriores a un parto eutócico, que fue el primero en su historial, tuvo un episodio de abundante metrorragia. En el puerperio inmediato tuvo una hemorragia abundante que requirió la transfusión de dos concentrados de hematíes. En la ecografía transvaginal el útero se observó de 22 x 44 mm, que podría corresponder a un cotiledón retenido. Ante la persistencia del sangrado se colocó un taponamiento intracavitario con una sonda de Foley con lo que se consiguió el cese del sangrado. Luego de descartar la embolización de las arterias uterinas debido al gran tamaño de la malformación arteriovenosa, se procedió a la histerectomía total simple por vía laparotómica. CONCLUSIÓN: Las malformaciones arteriovenosas uterinas, aunque son una causa infrecuente de hemorragia puerperal, deben ser sospechadas en virtud de ser potencialmente mortales.

Abstract BACKGROUND: Uterine arteriovenous malformations are a rare cause of puerperal hemorrhage, with only 150 cases reported in the literature. Their knowledge is important because they are life-threatening and because there has been an increase in recent years. They are usually related to interventions in the uterus: curettage, caesarean section or myomectomy or associated with neoplasms (gestational trophoblastic disease or endometrial adenocarcinoma), although others are congenital. CLINICAL CASE: A 32-year-old patient with a cervical conization and ablation of a uterine myoma by radiofrequency as the only history of interest. Fifteen days after a euthecological delivery, which was the first in her history, she had an episode of abundant metrorrhagia. In the immediate postpartum period, she had a heavy hemorrhage that required the transfusion of two red blood cell concentrates. Transvaginal ultrasound showed a uterus measuring 22 x 44 mm, which could correspond to a retained cotyledon. In view of the persistent bleeding, intracavitary tamponade was placed with a Foley catheter, which led to cessation of bleeding. After ruling out embolization of the uterine arteries due to the large size of the arteriovenous malformation, a simple total hysterectomy by laparotomy was performed. CONCLUSION: Uterine arteriovenous malformations, although an infrequent cause of puerperal hemorrhage, should be suspected because they are potentially fatal.

Tratamiento quirúrgico en estado epiléptico super refractario relacionado con malformación arterio venosa

Introducción: Las malformaciones arteriovenosas cerebrales (MAV) son un conjunto anormal de arterias y venas dilatadas del cerebro y caracterizadas por la pérdida de la organización vascular con una derivación arteriovenosa anormal. La probabilidad de ruptura de una MAV es baja, pudiendo causar déficit hasta en el 45% de los pacientes. La epilepsia puede asociarse con MAV siendo raro el estado epiléptico. La evolución a estado epiléptico refractario o estado epiléptico super refractario (EESR) es excepcional. Se presenta paciente con epilepsia asociada a MAV, con embolización y posterior complicación que evoluciona a EESR, donde se logró una resolución favorable con cirugía. Caso clínico: Paciente masculino de 70 años, con MAV temporal derecha no rota y epilepsia, libre de crisis desde el diagnóstico de ambas condiciones. Se realizó embolización logrando exclusión, pero con evolución a EESR. Tras estudio se realiza resección de MAV y resección parcial de zona de inicio de actividad epileptógena parieto-temporal. Además, se realizó una desconexión de región fronto-parietal central donde había evidencia de propagación de la actividad epiléptica. Paciente logra salir de estado crítico, con recuperación de conciencia y normalización de electroencefalogramas posquirúrgicos. A los 2 años evoluciona con epilepsia controlada (Engel IIa). Discusión y conclusiones: El abordaje quirúrgico es una opción en EESR y debe plantearse en un tiempo precoz de evolución (1-2 semanas). La cirugía se realizó para controlar EESR y fue una intervención exitosa. Esta estrategia puede lograr un cambio dramático en el pronóstico. La cirugía resectiva está indicada cuando hay evidencia etiológica en imágenes y focalidad eléctrica consistente en los estudios.

Introduction: Brain Arteriovenous Malformations (AVM) are an abnormal set of dilated arteries and veins within the brain and are characterized by loss of vascular organization with an abnormal arteriovenous shunt. The probability of AVM rupture is low, but it can cause deficits in up to 45% ofpatients. Epilepsy could be associated with AVM, and status epilepticus is rare. The evolution to refractory status epilepticus or super refractory status epilepticus (SRSE) is very rare. The objective is to present a patient with epilepsy associated with non-ruptured AVM, treated with embolization and a subsequent complication that evolves into SRSE, in which a favorable resolution was achieved after surgery Clinical case: 70-year-old male, with a diagnosis of non-ruptured right temporal AVM and epilepsy, who has been seizure free since the diagnosis, is reported. Embolization of the AVM was performed, achieving total exclusion, after the procedure presented seizures that evolved into SRSE. After investigation, an AVM resection and partial resection of the ictal onset zone on the right parieto-temporal region was performed, including a disconnection of the central fronto-parietal region, where there was evidence of propagation of ictal activity. Patient recovered from the critical condition after surgery, and also presented electrographic normalization. After 2 years, the epilepsy is well controlled (Engel IIa). Discussion and conclusions: The surgical approach is an option in SRSE, and it should be proposed early on, within a reasonable time of evolution (1-2 weeks). The active approach in this case, where the surgery was done for SRSE control, was a successful intervention. Especially when the features are consistent -there is etiological evidence in imaging and electrical focality in studies- there can be a dramatic change in the prognosis.

Pelvic arteriovenous malformation involving the uterine and internal iliac vessels with concomitant true aneurysm of uterine artery diagnosed through color Doppler ultrasound / Philippine Journal of Obstetrics and Gynecology

Background@#Pelvic arteriovenous malformations (AVMs) are rare but carries life-threatening consequences.@*Case Report@#A 47-year-old multipara who had previously undergone four cesarean sections came for re-evaluation of a malignant ovarian new growth. She was asymptomatic. Repeat ultrasound revealed normal ovaries, and a cystic structure at the left adnexa with abundant mixing of colors, turbulent flow and pulsative waveforms on spectral Doppler. It arises from serpentine tubular structures from the uterine isthmus. Uterine artery aneurysm was considered. Magnetic resonance angiography confirmed the findings of aneurysm and pelvic arteriovenous malformation. The patient underwent a hysterectomy with ligation and excision of aneurysm. Histopathologic findings showed pelvic AVM and a true aneurysm of the uterine artery.@*Conclusion@#Ultrasound with color Doppler is a low-cost and readily available tool for gynecologists for the diagnosis and management of pelvic AVM.

Metastatic placental site trophoblastic tumor with pelvic arteriovenous malformation: A case report / Philippine Journal of Obstetrics and Gynecology

@#Placental site trophoblastic tumor (PSTT) with uterine arteriovenous malformation (AVM) is a rare and potentially catastrophic occurrence. A high index of suspicion and immunohistochemistry secured the diagnosis. The use of appropriate imaging modalities led to the identification of the extent of the disease. Sequential planned management from neoadjuvant intensive chemotherapy, bilateral uterine artery embolization, and laparotomy, and coordinated among different medical disciplines resulted to a successful definitive treatment. Due to its relatively chemoresistant nature, hysterectomy is the mainstay of treatment. Adjuvant platinum-based intensive chemotherapy has been shown to improve overall survival in patients with metastatic disease and those with poor prognostic factors. This case of PSTT with a typical clinical profile was noteworthy due to the development of a significant AVM, a rare complication of PSTT. This case report included a review of treatment experiences as well as peculiarities that set PSTT apart from the more common gestational trophoblastic diseases.

The application of silent MR angiography in the imaging of brain arteriovenous malformation in children / 中华放射学杂志

Objective:To explore the application value of silent MR angiography (MRA) in imaging of brain arteriovenous malformation (BAVM) in children.Methods:A total of 20 children with BAVM confirmed by digital subtraction angiography (DSA) were retrospectively collected. All children were imaged by silent MRA and time-of-flight MRA (TOF MRA) in the same examination. The image quality of feeding artery, nidus and drainage vein of BAVM was evaluated using the four-point method. Wilcoxon rank-sum test was utilized to compare the image quality scores between silent MRA and TOF MRA. Weighted Kappa statistics used to evaluate the inter-modality agreement of silent MRA and TOF MRA with DSA in displaying of angioarchitecture characteristics and determination of Spetzler-Martin grading.Results:Among the 20 BAVMs, significant differences in image quality scores of the nidus (2.75±0.55 versus 2.20±0.70) and drainage vein (2.60±0.68 versus 2.20±0.77) were observed between silent MRA and TOF MRA ( Z=-3.05, P=0.002; Z=-2.13, P=0.033, respectively). The agreement between silent MRA and DSA was excellent in nidus size grading, deep venous drainage, associated aneurysm and SM grading (Kappa 0.91, 1.00, 0.83 and 0.93, respectively); The agreement between TOF MRA and DSA was fair to moderate (Kappa 0.46, 0.59, 0.35 and 0.47, respectively). Conclusions:Silent MRA showes better image quality compared to TOF MRA and improves the evaluation of angioarchitecture characteristics and Spetzler-Martin grading of BAVMs in children.

RASopathies: Dermatologists’ viewpoints

Ras/mitogen-activated protein kinase pathway dysregulation results in a group of disorders, collectively termed as RASopathies. Neurofibromatosis type 1, Noonan syndrome, Noonan syndrome with multiple lentigines, Noonan syndrome/loose anagen hair, Legius syndrome, Costello syndrome, cardio-facio-cutaneous syndrome and capillary malformation-arteriovenous malformation are the well- recognized RASopathies. These are characterized by multi-organ tumours and hamartomas. Some other features in common are facial dysmorphism, skeletal abnormalities, congenital heart disease, neurocognitive abnormalities and risk of various solid-organ and haematological malignancies. Some of the RASopathies are heterogeneous, caused by several gene mutations resulting in variations in phenotypes and severity ranging from mild to fatal. Significant phenotypic overlaps among different disorders, often makes it difficult to pinpoint a clinical diagnosis. Specific cutaneous manifestations are present in some of the RASopathies and are often the earliest clinical signs/symptoms. Hence, dermatologists contribute significantly as primary care physicians by identifying disorder-specific cutaneous lesions. However, diagnostic work-up and management of these disorders are often multidisciplinary. Confirmation of diagnosis is possible only by genetic mapping in each case. Genetic counseling of the patients and the affected families is an important component of the management. The aim of this review is description of cutaneous manifestations of RASopathies in the background of multi-system involvement to enable dermatologists a comprehensive and logical approach to work up and diagnose such patients in the absence of facility for specific molecular testing.

Malformación arteriovenosa posterior a la retención de productos de la concepción / Arteriovenous malformation after retention of products of conception

Resumen OBJETIVO: Plantear un procedimiento para pacientes con retención de restos corioplacentarios y riesgo de formación de fístulas arteriovenosas que sea efectivo, seguro y ambulatorio. MATERIALES Y MÉTODOS: Estudio de serie de casos, retrospectivo, de pacientes atendidas en el Hospital Gea González de enero a mayo de 2022. Se empleó un equipo de Bettocchi, de flujo continuo de 5 mm, lente cilíndrico de 2.9 mm y 30°. En casos específicos se programó un procedimiento quirúrgico con resectoscopio Richard Wolf Princess, con diámetro exterior de 7 mm, sistema óptico de 2.7 mm, dirección visual de 30°. RESULTADOS: Se revisaron 642 expedientes de los que se obtuvo una serie de 31 casos que se incluyeron conforme a la clasificación de Gutenberg, con biopsia por protocolo posaborto y resección con Grasper para los tipos 0 y 1; dos pacientes se enviaron a Urgencias por sangrado abundante para aspiración mecánica endouterina inmediata; dos pacientes se catalogaron con tipo 3; en la primera se optó por el tratamiento médico con metotrexato con lo que se consiguió la resolución completa y la segunda finalizó el embarazo con histerectomía laparoscópica. CONCLUSIONES: En pacientes con imágenes ecográficas sugerentes de retención de restos corioplacentarios o malformación arteriovenosa, los procedimientos con visión directa evitan las complicaciones inmediatas y futuras. El diagnóstico mediante la clasificación de Gutenberg permite definir el tipo de acceso con extracción en frío con pinza Grasper para los tipos 0 y 1, o la aplicación de una prueba farmacológica con metotrexato y resección histeroscópica para los tipos 2 y 3 en pacientes hemodinámicamente estables.

Abstract OBJECTIVE: To propose an effective, safe and outpatient procedure for patients with retained chorioplacental remnants and risk of arteriovenous fistula formation. MATERIALS AND METHODS: Retrospective case series study of patients attended at the Gea González Hospital from January to May 2022. A Bettocchi equipment was used, 5 mm continuous flow, 2.9 mm cylindrical lens and 30°. In specific cases a surgical procedure was scheduled with a Richard Wolf Princess resectoscope, 7 mm outer diameter, 2.7 mm optical system, 30° visual direction. RESULTS: We reviewed 642 files from which we obtained a series of 31 cases that were included according to the Gutenberg classification, with biopsy by postabortion protocol and resection with Grasper for types 0 and 1; two patients were sent to the ER for heavy bleeding for immediate MVA; two patients were categorized as type 3; in the first one we opted for medical treatment with methotrexate with which we achieved complete resolution and the second one ended the pregnancy with laparoscopic hysterectomy. CONCLUSIONS: In patients with ultrasound images suggestive of retained chorioplacental debris or arteriovenous malformation, direct vision procedures avoid immediate and future complications. Diagnosis by Gutenberg classification allows to define the type of access with cold extraction with Grasper forceps for types 0 and 1, or the application of a pharmacological test with methotrexate and hysteroscopic resection for types 2 and 3 in hemodynamically stable patients.

Clinical characteristics of 16 cases of acquired uterine arteriovenous malformation / 中国综合临床

Objective:To analyze the clinical characteristics, diagnosis and treatment of acquired uterine arteriovenous malformation (UAVM).Methods:The clinical data of 16 patients with diagnosis of UAVM from January 2014 to March 2021 in Beijing Friendship Hospital, Capital Medical University were enrolled in this retrospective study. The general data of patients were observed and analyzed: age, pregnancy and childbirth, etc. Auxiliary examinations: human chorionic gonadotropin (hCG), B-ultrasound, CT angiography (CTA), magnetic resonance (MRI), digital subtraction angiography (DSA), lesion diameter, resistance index (RI), peak systolic velocity (PSV), treatment and postoperative pathology.Result:Among the 16 patients, hCG was negative in 10 cases and positive in 6 cases. The first abnormal bleeding time was (43.4±36.4) days and (16.0±9.0) days, respectively. The rehospitalization time was (63.3±54.4) days and (48.3±54.0) days. Six patients with massive bleeding were HCG negative. Ultrasound in 16 cases showed mixed echo light mass with rich blood flow in the uterine cavity, and magnetic resonance examination in 14 cases also showed abnormal signals in the uterine cavity or uterine wall. Mass staining was seen in 6 cases by DSA, vein development in advance, contrast medium overflow was seen in 2 cases, and the conclusion of CTA was consistent with DSA in 5 cases. Uterine artery embolization was performed in 5 cases, including 2 cases of massive bleeding, emergency bilateral uterine artery embolization and 3 cases of preventive embolization. Hysteroscopy was performed in 4 cases after embolization, and balloon compression was performed in 1 case because there was no obvious tissue in the uterine cavity. Hysteroscopy were performed in 10 cases without UAE. Mifepristone combined with misoprostol was used in 1 case. Among the 15 patients treated by surgery, 14 cases showed degenerative trophoblasts or villi. During the follow-up, one patient after uterine artery embolization complained of decreased menstruation, and ultrasound considered the possibility of intrauterine adhesion.Conclusion:After termination of pregnancy, imaging examination should be strengthened to guard against the occurrence of UAVM. Once diagnosed, medical intervention should be started as soon as possible to reduce bleeding. There is no standardized treatment for UAVM related to pregnancy. Comprehensive consideration should be given to the clinical manifestations, bleeding situation, lesion location and fertility requirements of the patients.

A Unique Case: Arteriovenous Malformation of the Urinary Bladder Wall

ABSTRACT Arteriovenous malformation (AVM) of urinary bladder is a very rare condition in which a section of blood vessels lacks capillary vessels resulting in blood from an artery being delivered directly to a vein. We report a rare case of AVM of the bladder wall mimicking a bladder tumour presenting with acute abdomen.

A study on diagnosis and management of arteriovenous malformation of uterus

Background: Arteriovenous malformation is abnormal connection between an organ’s arterial and venous circulation. In acquired AVM, history of uterine procedure seems inevitable. Their clinical feature is usually vaginal bleeding. It is diagnosed by 2-D ultrasonography combined with colour doppler. Most of the time they resolve spontaneously; however, if left untreated, uterine artery embolization or hysterectomy comes in hand. The purpose of this study was to evaluate the role of TVUS and colour doppler in the diagnosis and follow-up of treated cases of uterine AVM. This study also aims to evaluate different modalities to manage uterine AVM.Methods: This was a retrospective study done at tertiary care centre from January 2018 to December 2019 to assess the presentation, treatment, and clinical pictures of patients with uterine AVM that were diagnosed with TVUS. Authors reviewed both (1) clinical data (2) ultrasound data of patients. The diagnostic criteria were “subjective” with a rich vascular network in the myometrium with the use of colour Doppler images and “objective” with a high PSV of 20 cm/sec in the vascular web.Results: Thirteen patients met the diagnostic criteria mentioned above. Out of that 100% presented with on and off bleeding per vaginum. Recent and remote history of uterine procedures were in found in 84.6% (n=11) of cases. UAE was done in 53.8% (n=7) cases. Thirty-three (33%) (n=5) cases spontaneously resolved when closely monitored with serial imaging and serum beta- HCG levels. Hysterectomy was needed in 7.4% (n=1) of patients of AVM.Conclusions: Uterine AVM occurred after unsuccessful pregnancies or uterine procedures. Triage of patients for expectant treatment, hormonal treatment vs intervention with uterine artery embolization based on their clinical status, which was supplemented by objective measurements of blood velocity measurement in the AVM, appears to be a good predictor of outcome.

¿Coartación de aorta en el recién nacido? No siempre es lo que parece: a propósito de un caso / Coarctation of aorta in a neonate? It is not always what it seems: an illustrative case

La coartación de aorta en neonatos se puede manifestar como insuficiencia cardíaca según el grado de obstrucción. Hay situaciones que pueden simular una coartación de aorta en los recién nacidos. Limitarse a la imagen típica de muesca aórtica en la ecocardiografía para diagnosticar una coartación de aorta puede inducir a error y demorar el diagnóstico adecuado. Se presenta el caso de un recién nacido con insuficiencia cardíaca con diagnóstico inicial de coartación de aorta y, posteriormente, de malformación arteriovenosa cerebral. Se debe considerar la malformación arteriovenosa en el diagnóstico diferencial de un recién nacido con insuficiencia cardíaca.

Coarctation of the aorta in neonates can manifest as heart failure when there is a certain degree of obstruction. There are some situations that can simulate a coarctation of the aorta in newborns. Diagnosis of coarctation of the aorta based solely on the typical aortic arch image on echocardiography can be misleading and delay an accurate diagnosis. We describe an unusual case of a newborn with heart failure who was initially diagnosed with coarctation of the aorta and then with cerebral arteriovenous malformation. We must consider the cerebral arteriovenous malformation in the differential diagnosis of a newborn with heart failure.

Abnormalities of the hallux skin and nail in the course of very rare arteriovenous malformation / Anormalidades de unha e pele do hálux no decorrer de malformação arteriovenosa muito rara

Abstract Arteriovenous malformations (AVMs) are usually found in the pelvic area and the brain. These vascular anomalies are rarely reported in the toes. AVMs in the toes may be asymptomatic, but can also cause atypical symptoms. Congenital AVMs can expand as patients age and manifest in adulthood. They may be provoked by injury. Acquired AVM might be caused by iatrogenic factors, venous or arterial catheterization, percutaneous invasive vascular procedures, surgery, or degenerative vascular disorders. An AVM can damage surrounding tissues and can cause destruction of skin, nails and bones. The course of the disease is often unpredictable and diagnosis is usually delayed as a result.

Resumo As malformações arteriovenosas (MAVs) são geralmente encontradas na região pélvica e no cérebro.. Essas anomalias vasculares raramente são relatadas nos dedos dos pés. A MAV nesse local pode ser assintomática ou apresentar sintomas atípicos. MAVs congênitas podem evoluir com a idade e se manifestar na idade adulta. O fator provocante pode ser uma lesão traumática. Uma MAV adquirida pode ser causada por fatores iatrogênicos, cateterismo venoso e arterial, procedimentos percutâneos vasculares invasivos, cirurgias e alterações degenerativas vasculares. A MAV pode danificar tecidos adjacentes e pode causar destruição de pele, unhas e ossos. O curso da doença é muitas vezes imprevisível, e como resultado, atrasar o diagnóstico.

Malformation of Wharton′s duct with multiple sialoliths: a case report and literature review / 口腔疾病防治

Objective@#To explore the diagnosis and treatment of ductal malformations of the submandibular gland with multiple stones.@*Methods@# A case of a malformation of Wharton′s duct with multiple sialoliths according to the clinical data, diagnosis and treatment of the patient was analyzed retrospectively.@*Results@#The patient′s physical examination and CBCT showed a tumor on the left floor of the mouth. In this case, it was found that the mass was a malformation of Wharton′s duct with multiple sialoliths according to operative exploration. The postoperative pathological examination showed (left submaxillary) salivation gland tissue, duct dilation and duct epithelia hyperplasia, duct calculus, and a large number of lymphocytes proliferating around the duct; 1 month after the follow-up, the patient had healed well. Through literature review and analysis, it was found that cases of submandibular ductal malformation with multiple stones were rare and should be carefully differentiated from arteriovenous malformation at the base of the mouth. Calculi of the submandibular gland can be removed by incision through the oral submandibular duct or by combined resection of the submandibular gland and ductal calculi, and some smaller calculi can also be treated by endoscopy of the salivary gland. @* Conclusion@# In cases of submandibular ductal malformation with multiple stones, intraoral and extraoral incisions should be performed simultaneously to remove the associated ductal stones.

Effect analysis of interventional therapy for hemorrhage of mandibular arteriovenous malformations / 中华放射学杂志

Objective@#To explore the therapeutic value of interventional methods for hemorrhage caused by mandibular arteriovenous malformations.@*Methods@#The clinical data of 7 patients (3 males and 4 females) with mandibular arteriovenous malformations treated by interventional therapy from January 2012 to January 2018 in the First Affiliated Hospital, Zhengzhou University were retrospectively analyzed. Of all patients, 4 patients suffered from sudden massive hemorrhage and 3 patients suffered from spontaneous repeated bleeding. The age ranged from 8.0 to 13.0 (10.6±1.7) years. Of the 7 patients, 3 underwent interventional embolization via arteries and veins, and 4 underwent embolization only via arteries. The embolic materials were polyvinyl alcohol granules and coils. The follow-up period was 9—18 months and the curative effect was observed.@*Results@#Among the 7 patients, 4 cases of acute massive hemorrhage were effectively controlled after interventional operation, 3 cases of chronic bleeding disappeared after interventional operation. No recurrence of bleeding occurred during the follow-up period, only 1 patient presented with oral infection and gingival swelling and hyperplasia. The symptoms were effectively controlled after anti-infection and debridement. No severe complications occurred in all patients.@*Conclusion@#Interventional therapy for ateriovenous malformation with hemorrhage is effective, safe and feasible, which is worthy of clinical application.

Fertility preserving surgical approach to uterine arteriovenous malformation / Philippine Journal of Obstetrics and Gynecology

@#Arteriovenous malformations (AVM) are vascular disorders with a mixture of arterial, venous and small capillary-like channels with fistulous connections. Uterine arteriovenous malformations are rare cause of abnormal uterine bleeding with only a few reported cases. They may arise from pregnancy, miscarriage, previous cesarean section or other uterine surgery and gestational trophoblastic disease. Diagnosis can be made through angiography or doppler ultrasonography. Traditionally, uterine AVMs are treated with hysterectomy but with the advances in technology, minimally invasive conservative approaches such as radiologic arterial embolization or laparoscopic uterine artery ligation have become available. We present a case of a 29-year-old, G2P1 (1011) who had a three- month history of heavy, intermittent vaginal bleeding from uterine arteriovenous malformation after a miscarriage. Laparoscopic bilateral uterine artery occlusion, offered a minimally invasive treatment with high symptomatic effectiveness.

Surgical feed ligation performed in 22 year old female with scalp arteriovenous malformation

Scalp arteriovenous malformation (AVM) are rare conditions that usually need surgical treatment. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complication. The etiology of scalp AVM may be spontaneous or traumatic. This vascular lesion present as scalp lump or a mass, grotesque, pulsatile mass with a propensity to massive haemorrhage. Various treatment option that have been adopted to treat these lesions include surgical excision, ligation of feeding vessel, trans arterial and transvenous embolization, injection of sclerosant into the nidus and electro thrombosis. A 22-years-old-female referred to cardiothoracic division with a 10 years history of a large fronto-parietal pulsatile reddish soft mass, progressively increasing in size, measuring about 15x6x2 cm, ulcerated area; without any symptoms and history of trauma. Three-dimensional CT angiography demonstrated a mass that was completely within the scalp and prominent vascular that was completely within the scalp and was not associated with bone or periosteum. The feeding arteries were originated from angular artery, supratrochlear artery, left and right superficial temporal artery. Surgical excision and ligation of feeding vessel was performed without complication. With pre-operative appropriate surgical planning, scalp AVM can be excised safely without any major complication. Though some cases may be treated with percutaneous or endovascular embolization, surgery remains the treatment of choice. In the event of scalp ulceration and haemorrhage, total excision is the only option.

Successful anesthetic management of a 17-year-old patient with facial arterio-venous undergoing sclerotherapy: a case report

Arterio-venous malformations (AVM) are abnormal collection of blood vessels. They are rare congential vascular malformations that account for 1.5% of all vascular abnormalities while 50% of such cases occur in the oral and maxillofacial region. Facial AVM are uncommon. Patients presenting with AVMs require a complete investigation using precise clinical examination and advanced imaging modalities. The treatment of a patient with AVM includes a multi-step process. In this case, we report a case of extensive AVM in the face of a 17-year-olf female patient. The report primarily focuses on the successful anesthetic management for sclerotherapy along with insights on clinical characteristics and imaging manifestations. To the best of our knowledge, this is one of the few cases to be reported in India.

4-Vessels Angiography: A Tinkering Tool In Multi-Faceted Manner.

Introduction:The global incidence of spontaneous intracranial vascular conditions such as: Spontaneous Subarachnoid hemorrhage (SAH); Nonaneurysmal subarachnoid hemorrhage (NASAH); and arterio-vascular malformation, which are low incidence conditions though lethal pathologies due to leakage of blood within the cranial cavity. Missed such conditions are mutual agony among healthcare providers. Management of these pathologies is imperative to an early diagnosis. Stimulatingly, despite the reiterated imaging studies that have been established for diagnosing intracranial vascular pathologies, 4-vessels angiography had ranked superior multidimensionally. Thus, this study targets to address the diagnostic significance of angiography in spontaneous intracranial hemorrhages as the cardinal tool of management with reference point comparison of our findings with those reported in literature. Methods: A retrospective chart review of patients presented with spontaneous intracranial hemorrhages over a period of 3-years from January 2014 till January 2017 at the neurosurgical department of King Hussein Medical Center was conducted. All patients had clinical features of sudden onset of severe headache, decrease level of consciousness of sudden neurological deficit, who were hospitalized within 72-hours after the bleeding onset. Clinical data, non-invasive radiological imaging studies confirmed the spontaneous intracranial hemorrhages presence. Patients underwent subsequent diagnostic workup. The results and complications of the Digital subtraction angiography (DSA) study were analyzed. Repeated DSAor computed tomography angiography (CTA) was performed 6-8 weeks later if initial angiographic result were negative. Results: Of 141-patients who underwent cerebral angiography following spontaneous subarachnoid hemorrhage in the three-year time period, 81- females (57.47%), 60-males (42.55%), mean age 50.76 year. Fifty four examinations revealed aneurysms, another 26- small aneurysms were diagnosed in the angiogram negative cases on the follow-up studies. Eighteen patients had non-aneurysmal subarachnoid haemorrhage, fourteencase showed arteriovenous malformation (AVM) and five-case showed dural fistula. Sixty-seven percent of the patients classified their headache as being the worst headache of their life and approximately 54 % described maximum intensity of the pain within the first 2-hours. Sudden loss of consciousness (LOC) occurred in 42% of the patients due to increased intracranial pressure. LOC often is transitory; however, approximately 15 % of the patients remained comatosed for several days. Seizures during the acute phase occurred in 16-patients (11.35%). Conclusion: Spontaneous intracranial hemorrhages is a devastating and multifarious disease which must be managed in well- established and dedicated centers. In our center, DSA following non-conclusive CT imaging of the brain was therefore a test of extremely high yield, utility, and also associated with decreased morbidity and mortality. Non-aneurysmal SAH cases have better neurological status compared with aneurysmalcases.