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IMAGE OF THE WEEK IMAGE OF THE WEEK PROF.DR.NOORUL AMEEN UNIT PROF.DR.NOORUL AMEEN UNIT DR.M.JAGADEESAN DR.M.JAGADEESAN I YR PG I YR PG

Imaging: AV Malformation

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Page 1: Imaging: AV Malformation

IMAGE OF THE WEEKIMAGE OF THE WEEK

PROF.DR.NOORUL AMEEN PROF.DR.NOORUL AMEEN UNITUNIT

DR.M.JAGADEESANDR.M.JAGADEESAN

I YR PGI YR PG

Page 2: Imaging: AV Malformation

41 yr old saravanan was admitted with 41 yr old saravanan was admitted with c/o vomiting 1 episode,altered c/o vomiting 1 episode,altered sensorium and difficulty in walking sensorium and difficulty in walking since morning.no h/o of trauma since morning.no h/o of trauma

Not a k/c DM ,SHT. Not a Not a k/c DM ,SHT. Not a smoker/alcoholicsmoker/alcoholic

o/e irritable nystagmus+,pooling of o/e irritable nystagmus+,pooling of saliva+,9saliva+,9thth and 10 and 10thth N palsy,b/l plantar N palsy,b/l plantar withdrawalwithdrawal

BP-120/80mm HgBP-120/80mm Hg

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Causes of intracranial Causes of intracranial hemorrhagehemorrhage

TraumaTrauma SHTSHT CoagulopathyCoagulopathy DrugsDrugs AVMAVM TumorsTumors aneurysmaneurysm

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Investigations Investigations

Echo normalEcho normal Coagulation profile normalCoagulation profile normal Homocysteine level slight increaseHomocysteine level slight increase

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The Spetzler-Martin grading system The Spetzler-Martin grading system helps predict the likelihood of helps predict the likelihood of satisfactory outcome if an attempt at satisfactory outcome if an attempt at surgical resection is made. The Spetzler-surgical resection is made. The Spetzler-Martin grade is determined by adding Martin grade is determined by adding the 3 individual scores from the table. the 3 individual scores from the table. High-grade AVMs are more difficult to High-grade AVMs are more difficult to resect, and, therefore, neurologic resect, and, therefore, neurologic deficits from the surgery itself are more deficits from the surgery itself are more likely. likely.

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Size of AVM*Size of AVM* Eloquence of Eloquence of adjacent adjacent brain†brain†

Pattern of Pattern of venous venous drainage‡drainage‡

Small (< 3 cm) Small (< 3 cm) 11

Noneloquent 0Noneloquent 0 Superficial only Superficial only 0 0

Medium (3-6 Medium (3-6 cm) 2cm) 2

Eloquent 1Eloquent 1 Deep Deep component 1component 1

Large (>6 cm) Large (>6 cm) 33

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* Measure the largest diameter of the nidus of the * Measure the largest diameter of the nidus of the lesion on angiography.lesion on angiography.

† Eloquent areas include sensorimotor, language, † Eloquent areas include sensorimotor, language, visual, thalamus, hypothalamus, internal capsule, visual, thalamus, hypothalamus, internal capsule, brain stem, cerebellar peduncles, and deep brain stem, cerebellar peduncles, and deep cerebellar nuclei. cerebellar nuclei. 

‡ The lesion is considered superficial only if all ‡ The lesion is considered superficial only if all drainage is via the cortical drainage system. drainage is via the cortical drainage system.

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A V malformationA V malformation

Lesions of the cerebral vasculature Lesions of the cerebral vasculature develop such that blood flows develop such that blood flows directly from the arterial system to directly from the arterial system to the venous system without passing the venous system without passing through a capillary system. The through a capillary system. The arteriovenous (AV) shunt is the arteriovenous (AV) shunt is the definitive characteristic of these definitive characteristic of these lesions. lesions.

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  AVMs are considered congenital lesions AVMs are considered congenital lesions and are characterized by a failure of the and are characterized by a failure of the embryonic vascular plexus to fully embryonic vascular plexus to fully differentiate and develop a mature capillary differentiate and develop a mature capillary bed in the affected area  Molecular biologic bed in the affected area  Molecular biologic factors are thought to be important to AVM factors are thought to be important to AVM development. These may include vascular development. These may include vascular endothelial growth factor (VEGF) and basic endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF). Tissues fibroblast growth factor (bFGF). Tissues adjacent to the AVM may be persistently adjacent to the AVM may be persistently mildly hypoxic because the malformation mildly hypoxic because the malformation may steal blood from adjacent healthy may steal blood from adjacent healthy tissue, further promoting angiogenesis. tissue, further promoting angiogenesis.

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Cerebral angiography provides Cerebral angiography provides definitive diagnosis. It documents a definitive diagnosis. It documents a functional AV shunt; however, functional AV shunt; however, because it is an invasive test, it is not because it is an invasive test, it is not performed as the first imaging study. performed as the first imaging study. Cerebral angiography also allows Cerebral angiography also allows grading of the AVM via the following grading of the AVM via the following Spetzler and Martin criteria. Spetzler and Martin criteria.

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