Av ms
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IntroductionIntroduction
Cerebral vascular malformations are widely classified as arteriovenous malformations(AVMs),cavernous malformation , venous malformations and telangiectasias based strictly on pathology , mixed or transitional types of malformations
The most common of the vascular malformation is the AVM (about 80%)
AVMsAVMsDEF. Are congenital ,high-flow ,high pressure lesions with primary Risk of devastating intracerebral hemorrhage
PathologyPathologyThe exact pathogenesis is not
knownA genetic factor has been
postulatedAVMs commonly affect distal
arterial branches Often found in the border zone
region shared by the distal anterior , middle and\or posterior cerebral arteries
Primitive circulation begins with a capillary mesh over the entire brain at about fourth week of embryogenesis
An AVM is a cluster of congenital arteriovenous communication without intervening capillaries
The arteries and veins are tortuous and dilated . Nidus is the actual site of the abnormal communication. In most, the AVM is visible in cortex
LocationLocation
They are more commonly supratentorial
particularly in parietal lobeMiddle cerebral Posterior cerebralAnterior cerebral territories are
involved in declining frequencies, nearly 10%.
10-15% of patients with this lesions are found to have aneurysm
LocationLocation
Clinical presentationClinical presentation
Intracranial AVMs are typically , diagnosed before the patient has reached the age of 40 years
Hemorrhage Spont. Hemorrhage most common 41-
79% Intraparenchymal , SDH or SAHIn 5-10% of case IVHSeizures 2nd most common symptoms
20-25%Focal neurological deficit about 10%
of AVMs Headache about 10-15% present with
headache aloneCognitive deficits especially in
children
Grade of AVMs(Grade of AVMs(Spetzler-Martin)
Lesion characteristicPoints Assigned
SIZESmall : diameter <3cm
Medium : diameter 3-6cm
Large : diameter >6cm
1
2
3
Location Noneloquent site
Eloquent0
1Pattern of venous drainageSuperficial only
Any deep 0
1
InvestigationsInvestigations
CT SCANSCT ANGIO MRI (MRA & MRV)DSA (digital subtraction
angiography)
ManagementManagement
Management strategies include MicrosurgeryEndovascular or radiosurgery either
alone or in combination .Surgical excision remains the gold
standard.
Axial magnetic resonance imaging with gadolinium shows an enhancing lesion in the left parietal cortex
Digital subtraction angiography (DSA) of the same patient shows an arteriovenous malformation(AVM) with a middle cerebral arterial feeder and a cortical draining vein to the superior sagittal sinus.
Intraoperative image of the same AVM shows the nidus on the cortical surface. Note the large draining vein with oxygenated blood going superiorly. Here, intraoperative cortical stimulation was attempted because of the eloquent location of the nidus
Post resection imagePost resection image..
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Dr.Abdullah AlsubaieeDr.Abdullah Alsubaiee