Primary non-traumatic intracranial hemorrhage. A municipal emergency hospital viewpoint.
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The devastating natural history of 138 consecutive admissions for non-traumatic intracranial hemorrhage to a major emergency care municipal hospital is reviewed. Sixty-four percent of the patients had demonstrable intracranial hematomas while 36% had mainly subarachnoid hemorrhage. Hypertension was a related condition in 43% of the parenchymal hematoma patients, while proved aneurysms accounted for 74% of the subarachnoid hemorrhage patients. There was only a 14% survivorship for patients requiring emergent surgery. All operated hematoma patients survived delayed surgery with improved level of responsiveness. The overall mortality was 74% for intracranial hematoma patients and 58% for aneurysm-caused subarachnoid hemorrhage patients. (+info)
Arteriovenous malformation of mesosalpinx associated with a 'vanishing' ectopic pregnancy: diagnosis with three-dimensional color power angiography.
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We describe two cases of pelvic arteriovenous malformation diagnosed with the aid of three-dimensional color power angiography. In both cases, beta-human chorionic gonadotropin (beta-hCG) increased to significant levels (8413 and 1560 mIU/ml, respectively); however, neither an intrauterine nor an adnexal gestational sac could be found. In each case, we observed an adnexal mass with several tortuous areas exhibiting abundant turbulent flow. The diagnosis of arteriovenous malformation was made and further assessment by three-dimensional color power angiography and magnetic resonance imaging (MRI) was carried out. The complex vascular anatomy of arteriovenous malformation, including its feeding vessels and drainage, was clearly depicted by three-dimensional color power angiography and correlated well with magnetic resonance angiography. Levels of beta-hCG decreased in subsequent tests, and eventually became negative 2-3 months later without and intervention. We believe that an involutional ectopic pregnancy induced the rapid growth of the arteriovenous malformations within the mesosalpinx. Three-dimensional color power angiography can be performed quickly and easily, using existing ultrasound equipment. It improves our understanding of complicated vasculature, and thus is a useful adjunct to two-dimensional and color Doppler ultrasound in the diagnosis of arteriovenous malformation. (+info)
Anaesthetic management of a woman who became paraplegic at 22 weeks' gestation after a spontaneous spinal cord haemorrhage secondary to a presumed arteriovenous malformation.
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A 19-yr-old woman developed a paraplegia with a T10 sensory level at 22 weeks' gestation. The spinal injury was caused by spontaneous bleed of a presumed arteriovenous malformation in the spinal cord. She presented for Caesarean section at term because of the breech position of her fetus. The successful use of a combined spinal epidural-regional anaesthetic is described and the risks of general and regional anaesthesia are discussed. (+info)
Expression of transforming growth factor-beta complex in arteriovenous malformations.
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The factors responsible for the development of cerebral arteriovenous malformations (AVMs) are not well known. Patients with hereditary hemorrhagic telangiectasia (HHT) have cutaneous vascular dysplasia and a high propensity to develop systemic and cerebral AVMs. Transforming growth factor-beta (TGF-beta) complex has been implicated in HHT. The aim of this study was to evaluate the expression of TGF-beta 1, TGF-beta 2, TGF-beta 3, and their two receptors (R1 and R2) in AVMs and in normal brain vessels. Formalin-fixed, paraffin-embedded tissues from 20 patients with cerebral AVMs (including two patients with HHT) were sequentially sectioned into 6 microns sections. Similar sections from normal brain tissue were obtained from five patients without AVMs and no intracranial pathology, who had died from unrelated causes. The normal tissue sections included large intracranial arteries, small arteries, venous sinuses, cortical veins, and brain tissue containing arterioles, capillaries, and venules. All specimens underwent immunohistochemical analyses with polyclonal antibodies to the following antigens: TGF-beta 1, TGF-beta 2, TGF-beta 3, and R1 and R2. The immunoreactivity, when present, was consistently noted in endothelial cells and in the medial smooth muscle. The intensity of vessel wall immunostaining was graded on a scale from 0 to 3. The mean staining grades of normal vessels for TGF-beta 1, TGF-beta 2, TGF-beta 3, R1, and R2 were 0.6 (range 0-1), 3, 2.8 (range 2-3), 1.6 (range 0-2), and 3, respectively, whereas the mean staining grades of AVM vessels were 0.3 (range 0-1), 0.8 (range 0-1), 0.6 (range 0-1), 1.4 (range 0-2), and 0.9 (range 0-1), respectively. The study thus demonstrated that normal brain vessels (arteries, veins, small vessels) have strong (range 2.8-3) immunostaining for TGF-beta 2, TGF-beta 3, and R2, and that the AVM nidus vessels have a paucity (range 0.8-0.9) of staining for these factors. In AVM vessels that had zero immunoreactivity to the above three factors, the vessel wall was fibrocollagenous rather than muscular. Further studies to examine the TGF-beta complex behavior in AVMs are needed. (+info)
Angioarchitecture related to hemorrhage in cerebral arteriovenous malformations.
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A retrospective study was conducted to determine the angioarchitecture related to hemorrhage in patients with cerebral arteriovenous malformations (AVMs), who underwent conservative treatment and long-term follow-up. The average observation period was 9.3 years, and the annual bleeding rate was estimated at 3.6%. In all cases angiographic findings were reviewed in detail. The average AVM grade by Spetzler-Martin was 3.5. Higher bleeding rate was observed in large AVM (5.4%) compared with small (2.1%) or medium AVM (2.9%). Deep venous drainage (8.6%/year) was strongly correlated to hemorrhage. Concerning location of nidus, hemorrhage was frequently found in insular, callosal, and cerebellar AVMs. Venous ectasia, feeder aneurysm, and external carotid supply were commonly demonstrated on angiograms. Comparison of annual bleeding rate revealed that AVMs with intranidal aneurysm (8.5%) and venous stenosis (5.5%) had a high propensity to hemorrhage. Therapeutic strategy should be focused on these potentially hazardous lesions by the use of endovascular embolization or stereotactic radiosurgery, even if surgical resection is not indicated. (+info)
Increased brain tissue oxygenation during arteriovenous malformation resection.
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The purpose of this study was to determine if baseline oxygen pressure (PO2), carbon dioxide pressure (PCO2), and pH in brain tissue adjacent to an arteriovenous malformation (AVM) is different from measures in control patients. In addition, PO2, PCO2, and pH changes were measured during the course of AVM resection. Two groups were studied. Group 1 (n = 8) were non-ischemic patients scheduled for cerebral aneurysm clipping. Group 2 (n = 13) were patients undergoing neurosurgery for AVM resection. Following craniotomy, the dura was retracted and a PO2, PCO2, pH sensor inserted into non-ischemic brain tissue in Group 1. In Group 2, the sensor was inserted into tissue adjacent to the AVM. Following equilibration, tissue gases and pH were measured during steady state anesthetic conditions in Group 1 and during AVM resection in Group 2. The results show that under baseline conditions before the start of surgery, tissue PO2 was decreased in AVM compared to control patients but PCO2 and pH were not changed. During AVM resection, PO2 increased, PCO2 decreased, and pH increased compared to baseline measures. These parameters did not change in control patients over a similar time period. The results suggest that chronic cerebrovascular adaptation occur in AVM patients with decreased tissue perfusion pressure as an adjustment for decreased oxygen delivery. During AVM resection, this adaptation produces a hyperemic environment with relative tissue hyperoxia, hypocapnia, and alkalosis which is not corrected by the end of surgery. (+info)
Multidisciplinary approach to arteriovenous malformations.
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The treatment of arteriovenous malformations (AVMs) depends on the efforts of a multidisciplinary team whose ultimate goal is to achieve better results when compared to the natural history of the pathology. The role of adjuvant treatment modalities such as radiosurgery and endovascular embolization is discussed. Treatment strategies and surgical results from a personal series of 344 patients operated in a 10-year period are reviewed. The Spetzler and Martin classification was modified to include subgroups IIIA (large size grade III AVMs) and IIIB (small grade III AVMs in eloquent areas) to assist the surgical resection criteria. The treatment strategy followed was surgery for grades I and II, embolization plus surgery for grade IIIA, radiosurgery for grade IIIB, and conservative for grades IV and V. According to the new proposed classification 45 (13%) patients were grade I, 96 (28%) were grade II, 44 (13%) grade IIIA, 97 (28%) grade IIIB, 45 (13%) grade IV, and 17 (5%) were grade V. As for surgical results 85.8% of the patients had a good outcome (no additional neurological deficit), 12.5% had a fair outcome (minor neurological deficit), 0.6% had a bad outcome (major neurological deficit), and 1.2% died. These figures indicate that the treatment of AVMs can achieve better results compared to the natural history if managed by a well trained group of specialists led by an experienced neurosurgeon. (+info)
Multimodality treatment for large and critically located arteriovenous malformations.
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To define the current status of the multimodality treatment for large and critically located arteriovenous malformations (AVMs), we have made a retrospective review of 54 consecutive patients with Spetzler-Martin grade IV and V AVMs. The size of nidus is larger than 3 cm in diameter in all cases. Initially, all but one were treated by nidus embolization with the aim of size reduction. Only one patient had complete nidus occlusion by embolization alone. In 52 patients, the obliteration rate of nidus volume averaged 60% after embolization. Ten patients underwent complete surgical resection of AVMs following embolization with no postoperative neurological deterioration. Thirty-one patients underwent stereotactic radiosurgery following embolization. At the time of this analysis, 30 patients underwent follow-up angiography 2-3 years after radiosurgery. The results of radiosurgery correlated well with the preradiosurgical AVM volume. Of 16 patients with small residual AVMs (< 10 cm3, a mean volume of 4.7 cm3), nine (56%) had complete obliteration, and six (38%) had near-total or subtotal obliteration by 3 years after radiosurgery. In contrast, of 14 patients with large residual AVMs (> or = 10 cm3, a mean volume of 17.9 cm3), only two (14%) had complete obliteration, and eight (57%) had near-total or subtotal obliteration. Repeat radiosurgery was performed for the patients with remaining AVMs at 3-year follow-up review. This study indicates that a certain number of large and critically located AVMs can be safely treated by either microsurgery or radiosurgery following a significant volume reduction by nidus embolization. The present data also suggest the need and possible role of repeat radiosurgery in improving complete obliteration rate of large difficult AVMs, since many of those AVMs have significantly responded to initial radiosurgery. (+info)