Multiple Dural Arte Rio Venous Malformations Coming From The

8/8/2019 Multiple Dural Arte Rio Venous Malformations Coming From The

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Multiple DuralMultiple Dural ArteriovenousArteriovenous

Malformations Coming from theMalformations Coming from the

Three Branches of the AnteriorThree Branches of the AnteriorCerebralCerebral ArteriesArteries


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The PatientThe Patient

48 year old, Male

A stevedore

Chief Complaint:


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History of Present IllnessHistory of Present Illness

2 months PTA2 months PTA

Widebased gait

headacheMemory

lapses

Irritability/low

attention

Decreasedlibido

1 year PTA1 year PTA

limping imbalance


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Past Medical HistoryPast Medical History

CraniectomyCraniectomy

3 years ago

EpiduralEpidural

hematomahematoma

due to traumadue to trauma


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Personal/ Social HistoryPersonal/ Social History

Non- smoker

Occasional Alcoholic beverage

drinker History of marijuana and cough syrup

intake in his early 20s.

Salesman/ Farm Manager Stevedore


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FamilyHistoryFamilyHistory

Cerebrovascular Accident

Hypertension


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Review of SystemReview of System

Skin: (-) lesion, brown hair

Lymph node: (-) lymphadenopathy

Bones, Joints and Muscle: (-) fractures, (-)dislocations (-) swelling

Head: (+) headache(+) headache, (-) seizure

Eyes: (-) blurring of vision, (-) discharges

Ears: (-) deafness, (-) discharge, (-) pain


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Nose: (-) discharge, (-) epistaxis

Neck: (-) enlarge lymph nodes

Respiratory: (-) cough, (-) dyspneaCardiovascular: (-) chest pain, (-)

exertional dyspnea, (-) orthopnea

Gastrointestinal: (-) diarrhea, (-)nausea, (-) vomiting


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Nervous System:

(-) photophobia,(-) blurring of vision,

(-) limitation in motion of neck

Allergies: None


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Physical ExaminationsPhysical Examinations

Gen Survey: awake, conscious, coherent,ambulatory, not in CR distress

Vi

talSi

gns:BP=1

20/80; CR-84;T=37

; RR=1

8

HEENT: pink palpebral conjunctiva, anictericsclera, (-) tonsillo pharyngeal congestion, (-)CLAD (-) bruit

Precordium: adynamic, PMI at 5th ICSMCL,

(-) murmur, (-) heaves


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Physical ExaminationPhysical Examination

CHEST: equal chest expansion, clearbreath sounds, (-) retraction, (-)

lagging

Abdomen: flat, soft, NABS, non tender,(-) organomegaly

Extremities: full equal pulses, (-) edema


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Neurologic ExaminationNeurologic Examination

Mental Status Exam:

Medium built, fairly groomed

abulic speech

Good eye contact

Depressed MoodFlat affect

Oriented to person, place time and situation


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MiniMini Mental Status ExamMental Status ExamMaximum

Score

PatientsScore Questions

5 4 What is the year? Season? Date? Day of the week? Month?

5 5 Where are we now: State? County? Town/city? Hospital? Floor?

3 3 The examiner names three unrelated objects clearly and slowly, thenasks the patient to name all three of them. The patients response is

used for scoring. The examiner repeats them until patient learns all of

them, if possible. Number of trials: ___________

5 2 I would like you to count backward from 100 by sevens. (93, 86, 79,

72, 65, ) Stop after five answers.

Alternative: Spell WORLD backwards. (D-L-R-O-W)

3 1 Earlier I told you the names of three things. Can you tell me what those

were?


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2 2 Show the patient two simple objects, such as a wristwatch and a

pencil,

and ask the patient to name them.

1 0 Repeat the phrase: No ifs, ands, or buts.

3 3 Take the paper in your right hand, fold it in half, and put it on the

floor.

(The examiner gives the patient a piece of blank paper.)

1 1 Please read this and do what it says. (Written instruction is Close

your eyes.)

1 1 Make up and write a sentence about anything. (This sentence mustcontain a noun and a verb.)

1 0 Please copy this picture. (The examiner gives the patient a blank

piece of paper and asks him/her to draw the symbol below. All 10

angles must be present and two must intersect.)


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Mini Mental Status Examination:22

Clock Drawing test was 3 GPCOG Screening Test Score of3

Clinical Dementia Rating of 1


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Cranial Nerve ExaminationCranial Nerve Examination

CN I can smell

CN II, III pupils equally reactive to light Fundoscopy:

OD OS

ROR (+) (+)

DISC clear disc margin clear disc margin

AVR 1:3 1:3

Venules Normal Normal

Exudates (-) (-)

Hemorrhage (-) (-)


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CN III,IV, VI: intact extraocular muscle

CN V: (+) corneal reflex

(+) can clench teeth

CN VII: (-) facial asymmetry, wrinkling of theforehead are equal and symmetrical

CN VIII: can hear

CN IX: (+) gag reflex

CN X: (+) gag reflex CN XI: can shrug shoulder

CN XII: tongue is at the midline


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5/5 4/5

4/55/5

100% 100%

100% 100%

motor sensory

R L

R L


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++

++ ++

++

DTR


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Nuchal rigidity(-)

Brudzinski: (-) Kernigs: (-)

Babinski: (-)


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Coordination:

No tremors

Can button his shirt and write word legibly

Slight loss of balance when allowed to standwithout support

Finger to nose: Normal

Rapid Alternating Movement: canpronate and supinate the hand, howeverhowever

slowing when ask to change the directionslowing when ask to change the direction


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DiagnosticsDiagnostics

CBC: Normal ECG: Sinus Rhythm

Crea: 85.20

Na: 151.00

K: 4.0

Chest Xray: Normal


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Ct SCANCt SCAN

Plain Contrast


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`4 Vessel Angiogram: AV MAL`4 Vessel Angiogram: AV MAL

AP View-1- Right AP view -2-Right


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AngiographyAngiography

Lateral View -1 Lateral View -2


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angiographyangiography

AP View- 1-Left Ap view -2-left


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Salient FeaturesSalient Features

48/M

Disorientation

Headache Right sided weakness

Decreased libido and poor attention

Depressed mood, flat affect

Monotonous and abulic speech Alcoholic bev drinker

(+) history of substance abuse (cannabis)


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Cranial nerves: intact

Motor: 4/5 on both the upper & lower ext

Tendency to fall to the right

Mild dysdiadochokinesia

Negative meningeal signs


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Differential DiagnosisDifferential Diagnosis

Multiple Emboli:1. Cardiac

2. Infectious origin

Multiple Cerebral

Aneurysms

Intracranial

Hemorrhage

CavernousMalformations


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48/M48/M

DisorientationDisorientation

HeadacheHeadache

Right sided weaknessRight sided weakness

Decreased libido and poor attentionDecreased libido and poor attention

Depressed mood, flat affectDepressed mood, flat affectMonotonous andMonotonous and abulicabulic speechspeech

AlcoholicAlcoholic bevbev drinkerdrinker

(+) history of substance abuse (cannabis)(+) history of substance abuse (cannabis)

Cranial nerves: intactCranial nerves: intact

Motor: 4/5 on both the upper & lower ext

Motor: 4/5 on both the upper & lower extTendency to fall to the rightTendency to fall to the right

MildMild dysdiadochokinesiadysdiadochokinesia

NegativeNegative meningealmeningeal signssigns


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Multi le ere r lMulti le ere r l rteri ve usrteri ve us

Malf r ati sMalf r ati s

Rare: 0.3- 4.9% of all AVMS

1.84% had multiple AVM

Dural AVMS:10-

14% of AVM

S

Female Preponderance

5th to 6th Decade

Left sided preponderance

5th to 6th Decade

1.84% had multiple AVM

Left sided preponderance


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Dural AVMsDural AVMs

nosoligically heterogenous group oflesions linked by similar architecture

Results to sinus thrombos

is 72%

May also precede their appearance

Signs and Symptoms*** location of the

lesionProgesssive memory impairment- 6-12%

Symptoms and Signs:Symptoms and Signs:

Memory impairmentMemory impairment-- 66--12%12%

FocalFocal neurodeficitsneurodeficits-- 55--14%14%HeadacheHeadache 4343--50%50%

Bruits/Bruits/ timmitustimmitus-- 6767--92%92%


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In our patientWIn our patientW

Cognitive impairment

Anterior cerebral arteries involvement

Result to:

ABULIA PARAPLEGIA

Tests:

MM

SE~ 22/30: m

ild cogn

itive

impa

irment

Clockdrawing test: minor deviations

GPCOG: cognitive impairment

Clinical Dementia Rating- Mild Dementia


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Dural AVMsDural AVMs

Course : BENIGN

Treatment:

~expectant observation to more involvedmultimodality treatment interventionssuch as both transarterial and transvenousembolization.

IN ourPATIENT:Memantin ~16th week of medication

No signs of progression of the symptoms


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ConclusionConclusion

Multiple Dural AV Malformationspresent according to their anatomical

location

Disorientation and memory lapses~ ACAterritory

Common manifestations with unsual

diagnosis AVMs- 0.3%-4.9% had multiple

involvements


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ConclusionConclusion

After extensive research

NO PUBLISHED INFORMATION ONINVOLVEMENT OF ALL 3 BRANCHES OF

THE BILATERAL ANTERIOR CEREBRALARTERIES


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GOOD DAY!!!!GOOD DAY!!!!

Multiple Dural Arte Rio Venous Malformations Coming From The

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