High altitude: an unusual cause of neurological deterioration in a patient with an arteriovenous malformation

High altitude associated with neurological deterioration is an unusual presentation for an arteriovenous malformation (AVM). A case report of a man with a left temporal occipital AVM who developed symptoms that were markedly intensified by exposure to high altitude is presented. The AVM was removed surgically, and all symptoms resolved. The pathogenesis of this unusual AVM symptom complex is discussed in this report.     

Three cases of scalp arteriovenous malformations

Three cases of scalp arteriovenous malformation (AVM) are presented and the pertinent literature is reviewed. Case 1 was a 50-year-old male who was admitted to hospital with a pulsatile mass involving the right parietal region. Selective angiography revealed a scalp AVM fed by bilateral superficial temporal and right occipital arteries. The AVM was embolized with Gelfoam pieces through catheterization and there was no evidence of recurrence of the lesion after follow-up period of three years. Case 2 was a 25-year-old male who was noticed to have a birth mark in the left occipito-parietal region and was hospitalized with a pulsatile gradually expanding mass after an episode of minor trauma in the same region. Selective angiography revealed a cirsoid type scalp AVM fed by bilateral superficial temporal and occipital arteries, and the authors performed a total resection of the mass because of selective Gelfoam embolization was not successful. Case 3 was a 49-year-old male who was hospitalized with the chief complaints of left tinnitus and pulsatile left supra-auricular mass. There was no history of trauma. Selective angiography revealed a scalp AVM fed by the left superficial temporal and occipital arteries and the authors performed a selective Gelfoam embolization and this was successful, but three months later, the AVM recurred and mainly fed by instead this was the left posterior auricular artery. Preoperative selective Gelfoam embolization followed by a total resection of the AMV with minimal blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)     

Four cases of intracranial AVM successfully treated by radiation therapy

We have treated three patients with conventional radiotherapy and one with stereotactic radiosurgery and report the follow-up results. Case 1 was of a 63-year-old woman who had a dural AVM in the right cavernous sinus. She was irradiated using 10MV X-rays with a total of 30Gy. Post irradiation angiography showed a complete absence of dural AVM. Case 2 was of a 62-year-old woman who had a dural AVM fed by the left external carotid artery in the right cavernous sinus. Embolization by gelfoam was performed before irradiation. The irradiation was given with a total dose of 30Gy. Post irradiation angiography showed disappearance of the dural AVM. Case 3 was of a 26-year-old woman who had a small AVM (about 20 x 15 x 15mm) in the posterior corpus callosum. An operation was performed but the AVM was not excised completely. We irradiated the residual AVM with a total of 30Gy. The follow-up angiography one year after treatment, showed disappearance of the AVM. She had no neurological deficit two years after the treatment. Case 4 was of a 14-year-old boy who had a small AVM (about 20 x 15 x 10mm) in the left anterior wall of the fourth ventricle. The AVM was located deeply, so an operation was not performed. Radiosurgery was undertaken four months after onset in Buenos Aires. The total dose was 36Gy. The follow-up angiography one year after treatment, showed disappearance of the AVM. He also had no neurological deficit two years after the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Language localization with activation positron emission tomography scanning.

We report the first instance of the use of 3-dimensional magnetic resonance imaging anatomically correlated to positron emission tomography (PET) scanning to identify language areas in a patient with an arteriovenous malformation (AVM) in the posterior speech region. The patient was a 24-year-old right-handed woman with an angiographically proven AVM (3-4 cm) in the left mid-posterior second temporal convolution in whom a left intracarotid injection of sodium Amytal produced significant language disruption. A baseline PET cerebral blood flow study identified the AVM, and an activation PET scan performed during the reading and speaking of simple words showed increased activity in the left parastriate cortex (the second visual area), in the left posterior third frontal convolution (Broca's area), and in the left inferior and midtemporal gyri (Wernicke's area). Increased activity was also noted in the right and left transverse temporal (Heschl's) gyri, in the left precentral gyrus, in the left medial superior frontal gyrus (the supplementary motor area), and in the right cerebellum. We conclude that activation PET scanning is useful in the preoperative assessment of patients who harbor cerebral AVMs in classically described speech regions.     

Optic nerve arteriovenous malformation causing optic apoplexy: case report

OBJECTIVE AND IMPORTANCE: Vascular malformations in the optic pathway are rare. Only one case of pathologically confirmed arteriovenous malformation (AVM) of the optic nerve has been reported previously. We document the case of a patient with an optic nerve AVM who presented with optic apoplexy that was diagnosed with the use of magnetic resonance imaging. CLINICAL PRESENTATION: A 15-year-old girl developed left visual disturbance of sudden onset while playing badminton. A magnetic resonance imaging scan disclosed left optic nerve swelling and intraoptical hemorrhage, although an angiogram did not reveal abnormal vessels. INTERVENTION: The patient underwent total removal of the hematoma and tangles of the abnormal vessels in the left optic nerve, which was diagnosed pathologically as an AVM. The patient recovered visual acuity, but the left visual field defect remained unchanged. CONCLUSION: Along with cavernous malformations and optic gliomas, AVMs can be a rare cause of optic nerve apoplexy. T2-weighted magnetic resonance imaging is useful in rendering the diagnosis of an optic nerve AVM, observed as a mass lesion consisting of serpiginous, tangled, low-intensity bands. Early surgical treatment is recommended to obtain a rapid recovery.     

Orbital drainage from cerebral arteriovenous malformations

OBJECTIVE: To describe the neuro-ophthalmic findings in patients with orbital drainage from cerebral arteriovenous malformations (AVMs). METHODS: We reviewed the records of 100 consecutive adult patients with cerebral AVMs who presented to our institution during a 4-year period. All patients with orbital drainage were identified, and their neuro-ophthalmic evaluations were reviewed. RESULTS: Three patients (3%) were identified with orbital drainage from a cerebral AVM. The first patient presented with typical chiasmal syndrome (reduced visual acuity, bitemporal hemianopia, and optic atrophy). Magnetic resonance imaging demonstrated a large left temporal and parietal lobe AVM with compression of the chiasm between a large pituitary gland and a markedly enlarged carotid artery. The second patient presented with headaches and postural monocular transient visual obscurations. Examination revealed normal visual function with minimal orbital congestion and asymmetrical disc edema, which was worse in the left eye. Magnetic resonance imaging revealed a large right parietal and occipital lobe AVM without mass effect or hemorrhage and an enlarged left superior ophthalmic vein. The third patient had no visual symptoms and a normal neuro-ophthalmic examination; a right parietal lobe AVM was discovered during an examination for the cause of headaches. CONCLUSION: Orbital drainage from cerebral AVMs is rare. Manifestations may include anterior visual pathway compression, dilated conjunctival veins, orbital congestion, and asymmetrical disc swelling.     

Arteriovenous malformation associated with moyamoya disease--case report.

The authors report a case of moyamoya disease accompanied by arteriovenous malformation (AVM). Angiography demonstrated typical moyamoya vessels on the right and early changes of moyamoya disease on the left. A small AVM in the left frontal lobe supplied by a distal branch of the middle cerebral artery (MCA) was also revealed. The AVM was surgically resected simultaneously with contralateral encephaloaponeurotic synangiosis for the moyamoya vessels. One month after surgery, left MCA occlusion at the origin occurred probably due to hemodynamic changes after the resection of the AVM.     

Localized amyloidosis of the seminal vesicle: a case report

Primary amyloidosis of the seminal vesicle is a rare disease entity. We report here a case of localized seminal vesicle amyloidosis with hematospermia. A 66-year-old man visited our hospital with a chief complaint of hematospermia. T2 weighted magnetic resonance imaging (MRI) showed a hypointensity mass in the left seminal vesicle. Needle biopsy revealed amyloidosis of the seminal vesicle. Without any specific treatment, the mass lesion disappeared on MRI, and hematospermia was improved.     

Spontaneous disappearance of a huge cerebral arteriovenous malformation: case report.

A case of spontaneous disappearance of a cerebral arteriovenous malformation (AVM) is reported. A 59-year-old woman, who had been diagnosed as having a huge AVM in the left occipital lobe 6 years before and who was monitored without treatment, complained of a sudden headache and vomiting. Computed tomography revealed an acute subdural hematoma, intracerebral hematoma, and subarachnoid hemorrhage, for which a craniotomy was performed. Cerebral angiograms performed 9 days after the operation demonstrated a decrease in the size of the AVM. Repeated cerebral angiograms performed a month later demonstrated complete disappearance of the AVM. Follow-up angiograms performed 19 months after hemorrhage confirmed complete disappearance of the AVM. Spontaneous disappearance is known to occur occasionally in small AVMs but rarely in huge ones such as the one presented here. Several possible mechanisms for spontaneous disappearance of AVMs are discussed.     

Clinical study of voiding disorders in patients with cerebrovascular accidents]

Cystometry and urethral pressure profile were determined in 41 patients (29 males and 12 females) with voiding disorders resulting from cerebrovascular accidents within one year after the episode. By clinical symptoms, they were classified into 3 groups, urge incontinence (14 patients, 34%), pollakisuria (10 patients, 24%) and dysuria (17 patients, 41%). Cystometrogram were classified into 3 types, hyperactive bladder (31 patients, 76%), normal bladder (5 patients, 12%) and hypoactive bladder (5 patients, 12%). All patients in both groups of incontinence and pollakisuria showed hyperactive bladder except one normal bladder, while in the group of dysuria 3 types of cystometrograms were observed. Bladder capacity in incontinence group showed tendency to be smaller than that in dysuria group who had hyperactive bladder. Maximum urethral pressure in incontinence group was significantly lower than that in pollakisuria group and dysuria group who had hyperactive bladder. Ten patients with cerebral cortical lesions (80%) showed hyperactive bladder and 60% of them showed incontinence. In patients with cerebral lesions who had hyperactive bladder, the maximum urethral pressure of patients with incontinence showed tendency to be lower than that of patients with pollakisuria and dysuria. The majority of 7 patients with thalamic lesions showed hyperactive bladder and normal urethral pressure, and had dysuria. Two patients with pontine lesions showed hypoactive bladder. These findings suggested that urge incontinence resulting from cerebrovascular accidents was due not only to hyperactive bladder but also to lower urethral pressure.     

Two cases of spinal arteriovenous malformation presenting with subarachnoid hemorrhage

Two cases of spinal arteriovenous malformation (AVM) with subarachnoid hemorrhage (SAH) are reported. The first case is that of a 14-year-old boy who was transferred to our hospital with a sudden onset of headache. Neurological examination revealed no motosensory deficit, but a brain CT showed a slight diffuse SAH. A left vertebral angiogram demonstrated intramedullary AVM in the cervical region of the spinal cord. This AVM was therefore occluded using a solid embolization material. The patient was then discharged without neurological deficit. The second case is that of a 67-year-old man who visited our hospital with a sudden onset of headache. Neurological examination revealed no motor or sensory deficit, but a brain CT showed SAH, which was dominant in the posterior fossa. Initial cerebral angiography demonstrated no abnormality such as cerebral aneurysm or AVM except for laterality of the C1 radiculo-meningeal artery. A second angiogram on day 11 demonstrated spinal arteriovenous fistula (AVF), which was fed by the left radiculo-meningeal artery and drained to the posterior spinal vein. Embolization for the AVF was performed using liquid material. He was then discharged without neurological deficit. These two cases revealed non-specific SAH symptoms and were indistinguishable from other ruptured aneurysms. Although the brain CT can show a slight SAH or posterior fossa dominant SAH, repeated angiography may be necessary to verify and conclude the diagnosis of spinal AVM.     

Two cases of elderly patients with ruptured AVM with contrast medium extravasation during cerebral angiography]

Two cases are reported of elderly patients who experienced intracranial extravasation of contrast medium (CM) during carotid angiography (CAG) for ruptured cerebral arteriovenous malformations (AVM). The first patient, an 87-year-old male with no history of hypertension, was admitted immediately following a loss of consciousness after swimming in a pool. CT scan revealed a large intracranial hematoma in the left frontal lobe. CAG performed 1 hour after his arrival revealed a small AVM, fed by the left anterior cerebral artery with concomitant extravasation of CM. The patient's condition subsequently deteriorated and he died the following day. The second patient, a 71-year-old female, was admitted to our hospital in a comatose state after complaining of a severe headache. CT scan revealed a right parietal lobe hemorrhage extending into the ventricles. CAG was performed and demonstrated a small AVM in the right parietal lobe with extravasation of CM. Following emergency removal of the hematoma and AVM, the patient regained consciousness although some motor deficits persisted. A literature review revealed that only 6 cases of CM extravasation with ruptured AVM have been previously reported. The 4 previous cases involved patients 9, 15, 33 and 66-year-old, the younger three of which had a good outcome. The patients reported here were much older, and had a much less favorable outcome. Thus, AVM with CM extravasation may have a better prognosis in younger individuals.     

Recurrence of AVM after disappearing on postoperative angiography--report of two cases

We reported two cases of recurrent arteriovenous malformation (AVM), which had been operated on before and these AVMs disappeared on postoperative angiography. The first case was a 13-year-old boy who had suffered from intracerebral hematoma at the age of nine years. The first angiography showed AVM located in the left central region, fed by peripheral branches of the anterior and middle cerebral arteries. Sixteen days after the onset, removal of the AVM was carried out. Postoperative course was uneventful and angiography showed that the AVM had disappeared. However, 4 years later, follow-up digital subtraction angiography showed that the AVM had reappeared in the operated region. Extirpation of the recurrent AVM was repeated. The second case was a 28-year-old woman who had presented intracerebral hematoma at the age of 23 years. Angiography revealed AVM located in the right posterotemporal region, fed by a temporal branch of the middle cerebral artery. Removal of the AVM was carried out one month after the onset. Postoperative neurological status was good and angiography showed no residual AVM. Five years later, enhanced CT scan demonstrated a linear enhanced area in the operated region. This led us to suspect recurrence of the AVM. Conventional angiography presented reappearance of the AVM, and reoperation was performed. Reported cases of AVM, which recurred after disappearing on postoperative angiography, were very rare. Small abnormal vascular channels located in the surrounding area of the main nidus may be left after the initial operation, and they may have grown to nidus some years later.(ABSTRACT TRUNCATED AT 250 WORDS)     

Adult pial arteriovenous fistula and superior sagittal sinus stenosis: angiographic evidence for high-flow venopathy at an atypical location. Case report

The authors present the case of a 69-year-old man who suffered from bilateral cortical venous hypertension due to a brain pial arteriovenous malformation (AVM) with a high-flow fistula. The AVM became complicated by the development of a high-grade stenosis of the posterior superior sagittal sinus (SSS). A comparison of cerebral angiograms obtained at different times revealed that the severe SSS stenosis had developed within a 5-year period and was located distal to the nidus of the left parietal AVM nidus, away from the entrance of the dominant superior superficial cortical draining vein into the SSS. The high-flow fistula was occluded with detachable coils and the AVM nidus was further embolized with acrylic. The SSS stenosis was mechanically dilated by means of balloon angioplasty and stent placement. This case provides angiographic evidence to support the hypothesis that a pial arteriovenous fistula in an adult can cause high-flow occlusive venopathy in a major sinus within a relatively short time and that this acquired high-flow occlusive venopathy can develop at an atypical location distant from the nidus of the AVM.     

Report of a case of a renal arteriovenous malformation presenting an unusual computed tomographic finding

A fifty-three-year-old woman was admitted for gross hematuria and left lumbago. She was diagnosed as having left renal arteriovenous malformation (AVM) by renal angiography, but contrast enhanced CT of her left kidney demonstrated a low density area of renal parenchyma adjacent to AVM. Because a renal tumor could not be denied completely, we performed translumbar nephrectomy. No renal tumor was found in the removed kidney, and she was diagnosed as having cirsoid type AVM of the left kidney. The low density area in contrast enhanced CT was suspected to be indicating the ischemic renal parenchyma due to the steal phenomenon of renal AVM. This is the first report of a renal AVM with ischemic renal parenchyma demonstrated by CT.     

Hemorrhage from moyamoya-like vessels associated with a cerebral arteriovenous malformation. Case report

The authors describe a case of subarachnoid hemorrhage from moyamoya-like vessels associated with an arteriovenous malformation (AVM) in a 44-year-old Hispanic man who presented with severe headache. The AVM was located in the left parietal lobe and the ipsilateral middle cerebral artery was occluded. Although the patient was initially neurologically intact, he began to experience neurological deficits from mild vasospasm, illustrating the sensitivity of the underperfused portion of brain surrounding an AVM. His neurological deficits improved with aggressive hydration and elevated blood pressure. After a 3-week period, the AVM was resected without complication and all of the patient's neurological deficits resolved. The authors review radiographic findings of this unique case.     

Infratentorial arteriovenous malformation associated with persistent primitive trigeminal artery--case report

A 58-year-old male presented with a rare association of an infratentorial arteriovenous malformation (AVM) and ipsilateral persistent primitive trigeminal artery (PPTA) manifesting as sudden onset of headache and vomiting. Computed tomography revealed subarachnoid hemorrhage, and digital subtraction angiography demonstrated an infratentorial AVM mainly fed by the left superior cerebellar artery via the left PPTA. The patient refused radical treatment for the AVM, and was conservatively treated. The adjacent AVM may have been important in the preservation of the PPTA, as blood flow into the infratentorial AVM via the PPTA and the hemodynamic stress to the PPTA could have disturbed the spontaneous closure of the PPTA.     

Clinical manifestations of 25 patients with prostatic-type polyps in the prostatic urethra

To clarify the clinical manifestations of prostatic-type polyps (PP) in the prostatic urethra, a sample of 25 patients with PP who presented themselves to our hospital with hematuria or hematospermia was reviewed with respect to their symptoms and endoscopic findings. Recurrence of the conditions was also investigated. The patients were 26 to 68 years old, with a mean age of 48.5 years. Sixteen patients (64%) had hematuria and 8 (32%) had hematospermia. A bloody urethral discharge was observed in 6 patients (24%). Analysis of the character of the hematuria showed that total hematuria occurred in 44% of the patients. In 38% of the patients with hematospermia there was the additional symptom of post-ejaculatory hematuria. PP developed beside the verumontanum in 18 patients (72%), on the posterior urethral wall lateral to the verumontanum in 4 patients (16%), and on the verumontanum in 7 patients (28%). The prognosis could be investigated only in 22 (88%) of the 25 patients. Two patients (9%) experienced reccurrence during the follow-up period (1 to 5.8 years, mean: 3.7 years). Consequently, special attention should be paid to the possibility of PP in the prostatic urethra, particularly the verumontanum and nearby area, during endoscopic examination, when diagnosing patients with hematuria, hematospermia or with bloody urethral discharge.     

Spinal dural arteriovenous malformation: report of an unusual case

We present an unusual case of a spinal dural arteriovenous malformation (AVM) which produced compression radiculopathy of the left S1 nerve root. The nerve root was compressed by epidural vessels, draining vessels, and the nidus, without the characteristic myelographic findings of a dural AVM. No feeding vessels could be identified. It is important to consider the possibility of a spinal dural AVM in middle-aged patients who suffer lumbosacral radiculopathy, even if myelography does not demonstrate the characteristic findings.     

Arteriovenous malformation of the spinal cord and cauda equina fed by branches of the internal iliac artery and associated with vertebral hemangiomas

A rare case of an arteriovenous malformation (AVM) of the spinal cord is presented. The patient was a 35-year-old man who experienced progressive paraparesis and rectovesical disturbances. In this patient a spinal AVM was fed by branches of the left internal iliac artery and was associated with a sacral hemangioma. An additional hemangioma of the third lumbar vertebral body was also found. On reviewing the literature, only 4 cases, including ours, of spinal AVM with feeding vessels originating from the internal iliac artery were found. One of these patients had an associated vertebral hemangioma.