ARTERIO-VENOUS MALFORMATION

Definition

Arteriovenous malformations (AVM) of the brain and spinal cord are tangles of abnormal blood vessels. They can form wherever arteries and veins exist.

Causes

The exact cause of arteriovenous malformations is unknown.

Risks

Family history—some types of arteriovenous malformations are from genetic defects that can be passed on from one generation to the next.

History of bleeding—some types of arteriovenous malformations are linked to an increased risk of bleeding. People with unexplained recurrent bleeding may be at higher risk of having arteriovenous malformations.

Smoking

Symptoms

Seizures Headache, especially on one side of the head Muscle weakness Lightheadedness Loss of coordination, especially when walking Difficulty speaking or understanding language Loss of senses / Visual problems Memory loss Difficulty thinking or mental confusion Hallucinations

Diagnosis

Angiography or arteriography Computed axial tomography (CT

scan) Magnetic resonance imaging (MRI) Magnetic resonance angiogram

(MRA)

Treatment

Microsurgery Radiosurgery Endovascular (embolization)

Radiosurgery

very successful at treating small to medium-sized AVMs.

Obliteration (destruction) rates for AVMs less than 3 cm in diameter are about 80 to 85%.

Microsurgery

Endovascular Treatment

Associated symptoms

Examination

Vital signs Physical examination Neurologic Examination

Glasgow Coma Scale

ER Management

ABCs of resuscitation IVF Blood glucose level Medical or structural cause?

Medical Cause

Additional laboratory and radiologic tests Infectious Metabolic Toxicologic

Structural Cause

Cranial CT scan Refer to neurosurgeon

Case Scenario

Chief Complaint: vomiting and loose stools. History: fever, vomiting, irritable , (-)

fall/trauma Physical Examination:

drowsy, irritable, (+) seizure BP80/60 PR 130 RR 38 Temp 39oC CBG

40mg/dL soft-tissue contusion over the left scalp and

ecchymosis Chest: clear breath sounds Abdomen: globular, hyperactive BS, soft, non

tender, (+)multiple 1- peso-like marks on the anterior abdomen

Extremities are cool and mottled.

Additional Information

History Bleeding tendencies Associated medical problems

Neurologic Exam Pupils Funduscopic findings Motors: preferential movement

Social History Caregiver Socio-economic status Educational attainment of parents/caregiver

DIAGNOSIS?

Differentials

Medical Structural

Electrolyte abnormality

Encephalopathy Infection (sepsis) Intussusception Meningitis and

encephalitis Uremia (hemolytic-

uremic syndrome)

Cerebral vascular accident

Cerebral vein thrombosis

Hydrocephalus Intracerebral tumor Subdural empyema Trauma (intracranial

hemorrhage, diffuse cerebral swelling, shaken baby syndrome)

Management

Blood work-up Imaging

Cranial CT scan Xrays

CHILD ABUSE

Shaken Baby Syndrome

Definition: SBS is the vigorous manual shaking of an infant who is being held by the extremities or shoulders

Whiplash-induced intracranial and intraocular hemorrhage

No external signs of head injury

Presenting Symptoms

Frequently non-specific May be seen first in the outpatient

setting URTI, vomiting, irritability (23%) Respiratory distress Diarrhea, poor feeding Lethargy/decreased level of

consciousness Apnea, seizure, history of minor trauma

Symptoms

History must match physical findings High index of suspicion when non-

specific symptoms and history are at odds

Signs on Physical Exam

Retinal hemorrhage Bulging fontanel Pupillary changes Other physical injuries:

Fractures, soft tissue injuries, bruises Mechanism of injury/history does not

coincide with presenting signs

Diagnosis

CT scan – method of choice

Diagnosis

Ophthalmologic consult Retinal hemorrhage (75-90%)

Minimal external signs (one of the hallmarks of SBS)

Bulging fontanelle in 55% of infants with subdural hematoma

Findings

The Brain Subdural hemorrhage Subarachnoid hemorrhage Diffuse axonal injury Edema/infarction Parenchymal contusion Parenchymal hemorrhage

The Eye Retinal hemorrhage Vitreous hemorrhage Papilledema Retinal detachment Disruption of eye contents

The Bones Rib fractures Skull fractures Long bone injuries:

Periosteal stripping Metaphyseal fractures Shaft fractures

Prognosis

Significant morbidity (50%) and mortality

(15%)

SBS Complications

Developmental delays Behavioral problems Mental retardation Post-traumatic hydrocephalus, cerebral

atrophy Permanent brain damage Seizures Paralysis Blindness Deafness

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