Case Of Arteriovenous Malformation Research Articles

AVM presenting with seizure and hemorrhage

Background: Cerebral arteriovenous malformations (AVMs) have been long thought to be a congenital anomaly of vasculogenesis in which arteries and veins form direct communications forming a vascular nidus without an intervening capillary bed or neural tissue. Scattered case reports have described that AVMs may form de novo suggesting that they can become an acquired lesion. Case report: Our case, a 32-year-old, right-handed, male presented with new onset seizure with history of previous episode of intracerebral hematoma which was confirmed by CT scan of brain for which surgical evacuation was performed 8 years back. Post-operative recovery was uneventful and no episode of seizure was noticed at that time. Five years later, he developed new onset of seizure which was partially controlled by conventional Antiepileptic drugs. Conclusion: This case was initially a case of congenital small cerebral AVM that bleeds and subsequently developed new onset of seizure which became intractable. It indicates that cerebral AVM is a congenital vascular lesion.

A Case of Arteriovenous Malformation of the Lower Lip

A Case of Arteriovenous Malformation of the Lower Lip

Клінічний випадок артеріовенозної мальформації у вагітної жінки

Extragenital pathology during pregnancy and childbirth occupies a leading place in maternal mortality and perinatal pathology. One of the main ways to maintain the health of mother and child is to identify somatic diseases in pregnant women and timely treat them. Nervous system diseases that occur in pregnant women are mainly epilepsy, multiple sclerosis, brain tumors, cerebrovascular disorders, although remain poorly understood, but require immediate decisions to prolong pregnancy, obstetric tactics during childbirth, conservative or conservative surgery. The pathology of cerebral vessels (arterial aneurysms and arteriovenous malformations) also remains an urgent problem, despite many years of experience in their diagnosis and treatment. The sudden development of symptoms, severity of clinical manifestations and high mortality in rupture of an aneurysm or arteriovenous malformation of cerebral vessels determine the urgency of this problem and increased interest in its study, especially in pregnant women. Material and methods. The paper presents a clinical case of arteriovenous malformation in a 25-year-old pregnant woman, her treatment and delivery. Results and discussion. Arteriovenous malformation is considered a congenital cerebrovascular pathology, which is accompanied by a sudden rupture of abnormal vessels with the development of hemorrhagic stroke, without specific clinical symptoms and precursors, which complicates lifelong diagnosis. Endovascular embolization during pregnancy saved the lives of women and children. An effective result was obtained after neurosurgical treatment of arteriovenous malformation in a pregnant woman in the second trimester of pregnancy (17 weeks), which allowed to bring the pregnancy to the physiological time of delivery. Taking into account the complex neurological pathology, neurosurgery, which requires the exclusion of a powerful period of childbirth, a pregnant woman gave birth by cesarean section at 38 weeks of pregnancy. Conclusion. An effective result was obtained after neurosurgical treatment of arteriovenous malformation in a pregnant woman in the second trimester of pregnancy, which allowed to bring the pregnancy to the physiological time of delivery. The obtained results indicated the possibility of full-term pregnancy, reduction of maternal and perinatal morbidity and mortality in pregnant women with arteriovenous malformation with timely preventive and curative measures with timely referral of pregnant women to the perinatal center on the basis of a multidisciplinary clinical institution to prevent complications

Microsurgical resection of high-flow cerebral arteriovenous malformations after recurrent stroke

Arteriovenous malformations (AVMs) are tangled lesions that may digress the blood flow particularly the high flow ones and microsurgical resection is challenging. The natural history of AVM is not completely understood and its management is controversial. Microsurgical resection of cerebral arteriovenous malformation is a challenging procedure, particularly for high-flow type. Embolization, microsurgery, or radiotherapy are treatment options. Preoperative planning to control the feeders, arachnoid dissection around the AVM for identification and control of all arterial feeders around the AVM surfaces, lastly control of draining vein is the principal of microsurgery. The goal of surgery is to remove the AVM completely to eliminate the risk of bleeding avoiding neurological deterioration. In this paper, we reviewed a case of high-flow cerebral AVM in recurrent bleeding with successful microsurgical resection.The patient in this case report significantly improved his neurological condition and demonstrated a good quality of life during long-term follow-up. The results of this study showed that the microsurgical removal of AVMs represents an efficient treatment with good clinical outcomes. In the future, more investigations of the factors that lead to AVM rupture are required for the advancement of effective medical procedures.

Automated Deep Learning-Based Image Segmentation for the Correction of Normal Brain Dose-Volume Parameters in Brain SRS for Cerebral AVMs

Brain radiation necrosis (RN) is a dose-limiting toxicity of stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs). Prior studies show a significant relationship between the probability of RN and the volume of brain receiving high doses, in particular, the volume receiving at least 12Gy (V12). However, due to the prohibitive time cost of manually segmenting brain from other intracranial tissues, prior studies have treated all intracranial tissues homogenously as brain. Large AVMs can cause significant anatomical distortions, with dilated ventricles, draining veins, and embolized nidus elements potentially displacing brain tissue from the high dose volume. We hypothesized that there would be a significant difference between estimated V12 for all intracranial tissues (V12ic) and V12 for brain parenchyma specifically (V12brain) in AVM cases. To assess the difference between V12ic and V12brain (ΔV12), we used a convolutional neural network (CNN) to auto-segment magnetic resonance images (MRIs) from SRS-treated patients into vascular structures, CSF, and brain tissue, fusing the segmented images with treatment plans to calculate V12ic and V12brain. SRS plans from 8 AVM patients who underwent single stage SRS and 4 who underwent multistage SRS were included. For multistage SRS plans, each stage was treated as an independent plan, for a total of 16 analyzed treatment plans. A previously trained CNN was used to automatically segment multiparametric pre-treatment MRIs into arteries, veins, CSF, embolized vessels, and brain parenchyma. Segmentation labels were converted into contours and registered to treatment plans. Dose-volume histograms were generated, from which V12ic and V12brain for all intracranial tissue and brain parenchyma, respectively, were analyzed. We assessed the relationship between ΔV12 (V12ic - V12brain) and target volume using linear regression. Median target volume was 1.75cc (range [0.22-9.95cc]). Median V12ic was 8.31cc (range [2.1-21.4cc]) while median V12brain was 4.0cc (range [1.3-13.3cc]). Median ΔV12 was 3.7cc (range [0.46-9.4cc]). There was a significant linear relationship between target volume and ΔV12 (Pearson r2 = 0.57, p < 0.01), with larger targets associated with a greater ΔV12. Anatomical distortions produced by an AVM nidus can produce a significant difference between V12ic and V12brain, an effect that is more pronounced for larger lesions. Further studies are needed to directly assess the relationship between V12brain and likelihood of post-SRS RN; however, estimating dose to brain tissue specifically may help identify patients who can safely receive dose-escalated therapy as well as patients who require a more conservative approach. CNN-based automated segmentation provides a means of overcoming the previously prohibitive time cost of performing such an analysis.

Uterine Artery Embolization and Hysterectomy: An Interesting Case of Pelvic Congestion Syndrome and Uterine Arteriovenous Malformation

Study Objective The purpose of this video is to review a case of severe pelvic congestion and uterine arteriovenous malformations (AVMs) that was managed operatively with uterine artery embolization followed by immediate hysterectomy. Our objectives include: • Review the risk factors, diagnosis, and treatment of uterine arteriovenous malformations. • Describe the clinical course of a patient referred to our MIGS clinic for uterine artery embolization and hysterectomy. • Consider postoperative expectations for a patient after embolization and hysterectomy for pelvic congestion syndrome and AVMs. Design This is a case report. Setting Interventional radiology operating room and robotic operating room. Patients or Participants 41yo patient referred to our clinic from an interventional radiologist for surgical treatment of severe pelvic congestion syndrome with an intrauterine arteriovenous malformation. Interventions Uterine artery embolization and robotic-assisted total laparoscopic hysterectomy Measurements and Main Results N/A Conclusion Our case report emphasizes that uterine artery embolization before hysterectomy can help decrease blood loss for severe pelvic congestion syndrome and known AVMs. To achieve these favorable outcomes, coordination with interventional radiology, anesthesia, and the OR staff is necessary.Postoperatively, patients may have a fever due to the uterine artery embolization. Additionally, pelvic fluid collections may be due to inflammation and increased blood flow to the area due to the known pelvic congestion. These postoperative changes may present similarly to a pelvic abscess, but our patient was successfully managed expectantly.

Arteriovenous malformation drained into a developmental venous anomaly: A case report and up-dated literature review

IntroductionAlthough the association of developmental venous anomalies (DVAs) with cavernous malformations is well documented, the association with arteriovenous malformations (AVM) is unusual. The aim is herein to report an additional case and to review the concepts associated to these mixed malformations in order to guide patient management. MethodsA case of AVM associated with a DVA was identified and a literature review was performed according to PRISMA guidelines. Case reportIn an 18-year-old man presenting with sub-acute headache but with a normal neurological examination, the MRI-scan showed a right occipital DVA associated with hemosiderin spots evocative of earlier asymptomatic bleedings. The Digital Subtraction Angiography revealed a right parieto-occipital Spetzler-Martin Grade III AVM, fed by branches from the right middle and posterior cerebral arteries, with a superficial drainage flowing into a DVA that then joined the superior sagittal sinus. Multistep embolization was performed, leading to a partial reduction of the nidus, but preserving the DVA permeability. After a six-year follow-up. bleeding did not recur and the MRI aspect of the malformation was perfectly stable. ConclusionThe co-occurrence of a DVA and an AVM is rare but has a higher bleeding risk than AVM alone (69% vs 38%) and must consequently be suspected when a DVA is revealed by a haemorrhage, in the absence of associated cavernoma. These mixed malformations represent a therapeutic challenge which has to be tailored to the venous anatomy and to the malformation Spetzler-Martin grade. DVA permeability should be preserved to avoid deleterious venous infarction.

S2987 Arteriovenous Malformation of Stomach: A Rare Case of Symptomatic Non-Bleeding Gastric Subepithelial Lesion

INTRODUCTION: Gastric arteriovenous malformations (AVM) are rarely been reported. They are uncommon cause of upper gastrointestinal bleeding and abdominal pain. Here we report an unusual case of a middle-aged female who presented to us with intermittent epigastric discomfort and was diagnosed as a case of gastric AVM also mimicking dieulafoy lesion. CASE DESCRIPTION/METHODS: A 50-year-old female with a past medical history of hypertension, hyperlipidaemia, GERD, and depression was admitted to the hospital with intermittent epigastric discomfort, bloating, and decreased appetite for 4 months. There was also a history of 10 lbs of weight loss. There was no history of dysphagia or odynophagia. Physical examination was within normal limits and laboratory investigations were unremarkable. CT abdomen was performed due to concerns of weight loss which revealed a 1.5 cm lesion in the gastric fundus. The patient underwent an EGD which showed 1.5 cm subepithelial lesion with smooth overlying surface present in the gastric fundus with no ulcerations. Differential diagnoses included GIST, leiomyoma, and carcinoid. Endoscopic ultrasound was performed which showed the presence of 11.8 mm × 10.1 mm hypoechoic lesion which appears to be arising from the submucosal layer with mild internal vascularity. The muscularis propria layer appeared intact. A complete endoscopic mucosal resection was performed. Pathology was sent and showed benign gastric mucosa with proliferation of blood vessels in the submucosa. Although the vessels were prominent, but they were not large or tortuous as seen in Dieulafoy's lesion. Patient was later discharged on oral proton pump inhibitor for 4 weeks. On follow up clinic visit she remained asymptomatic and improved clinically. DISCUSSION: Gastric AVMs represent 1.4% of all intestinal AVMs. It is a congenital lesion with direct connection between its arterial and venous component. Gastric AVMs are diagnosed on endoscopy and treatment mostly involves endoscopic removal or surgery. The gastric AVM in our case mimicked a dieulafoy lesion. However the pathology confirmed it to be an gastric AVM.Figure 1.: EGD showed a 1.5 cm subepithelial lesion with smooth overlying surface present in the gastric fundus with no ulcerations.Figure 2.: EUS showing a 11.8 mm × 10.1 mm hypoechoic sub-epithelial lesion which appears to be arising from submucosa with mild internal vascularity.Figure 3.: Histopathology showed benign gastric mucosa with proliferation of blood vessels in the submucosa. Although the vessels are prominent, they are not large or tortuous as seen in Dieulafoy's lesion.

Novel Approach of Linear Accelerator-Based Stereotactic Radiosurgery in an Adult Patient With Brain Arteriovenous Malformation: A Case Report and Clinical Outcome

Stereotactic radiosurgery (SRS) is a proven strategy for treating the central nervous system arteriovenous malformation (AVM). We intend to present a case of cerebral AVM in an adult patient, successfully treated with a linear accelerator (LINAC) based SRS using simplified setup techniques and an advanced planning system. In the current scenario, frame-based SRS is the standard of care with LINAC. Recently, it has proven that even frameless SRS has similar results. In our case, we used a frameless SRS technique with similar results. While calculating the dose in radiotherapy planning, we used the Acuros™ algorithm, which has proven dosimetric advantages compared to the traditional AAA™ algorithm.

A Case Report Of Cerebral Arterio Venous Malformation Treated With Frameless Stereotactic Radiosurgery

Central nervous system Arterio-venous-malformations (AVM) are relatively rare developmental anom-alies in both paediatric and adult populations. It is although not very rare to treat these AVM’s with radiosur-gery. There has been multiple case series published in literature about the possible treatment options and role of Stereotactic radiosurgery (SRS). Gamma Knife, Cyber knife, Linac based SRS and Proton beam radiosurgery are different options used for the delivery of SRS. We intend to present a case of cerebral AVM in an adult pa-tient, successfully treated with Linac based SRS using simplified setup techniques and advanced planning sys-tem. Keywords: Case report, Stereotactic Radio Surgery , Arterio-Venous-Malformations , Acuros, Radiotherapy

Uterine Arteriovenous Malformation after First Trimester Termination of Pregnancy in a Patient with Hereditary Haemorrhagic Telangiectasia

Hereditary haemorrhagic teleangiectasia (HHT) is a rare autosomic dominant genetic disorder, characterised by epistaxis, cutaneous teleangiectasias, and arteriovenous malformations (AVMs) located mainly in lungs, gastrointestinal tract, liver, and central nervous system. We report a case of uterine arteriovenous malformation acquired after medical pregnancy interruption in a patient with HHT, discussing the atypical genetic setting and the strategy for the case management.

Stereotactic Gamma Knife Radiosurgery for Extracranial Arteriovenous Malformations

Introduction: Head and neck extracranial arteriovenous malformations (AVMs) are rare pathological conditions which pose diagnostic and reconstruction challenges. Stereotactic radiosurgery (SRS) is nowadays an established treatment method for brain AVMs, with high obliteration and low complication rates. Here we describe the first report of head extracranial AVMs successfully treated by Gamma Knife (GK) as a retrospective historical cohort. Methods: Over a 9-year period, 2 cases of extracranial AVMs were treated by GK Perfexion (Elekta Instruments AB, Stockholm, Sweden) at a single institution. A stereotactic frame and multimodal imaging, including digital subtraction angiography (DSA), were used. The prescribed dose was 24 Gy at the 50% isodose line. Results: The first case was of a patient with pulsating tinnitus and left superficial parotido-condylian AVM. Embolization achieved partial obliteration. Tinnitus disappeared during the following 6 months after GK. The second case was a patient with repetitive gingival hemorrhages and right superior maxillary AVM, fed by the right internal maxillary and facial arteries. Embolization achieved partial obliteration with recurrence of symptoms. GK was further performed. DSA confirmed complete obliteration in both patients. Conclusions: Single-fraction GK radiosurgery appears to be safe and effective for extracranial AVMs. We recommend prescribing doses that are comparable to the ones used for brain AVMs (i.e., 24 Gy). A stereotactic frame is an important tool to ensure higher accuracy in the context of these particular locations. However, in selected cases, a mask could be applied either for single fraction purposes (if in a non-mobile location) or for hypofractionation, in case of larger volumes. These findings should be validated in larger cohorts, inclusively in terms of dose prescription.

Usefulness of CT angiography for characterizing cerebral arteriovenous malformations presenting as hemorrhage: Comparison with digital subtraction angiography

ObjectiveTo compare the usefulness of CT angiography against the gold standard, digital subtraction angiography (DSA), in the characterisation of cerebral arteriovenous malformations (AVM) that present with bleeding. Material and methodsWe retrospectively analysed patients with intracranial bleeding due to an AVM who were included in a prospective database in the period comprising January 2007 through December 2012. We reviewed radiologic variables such as the characteristics of the AVM (size, location, presence of deep venous drainage), involvement of eloquent areas, and the presence of associated aneurysms. Two neuroradiologists blinded to clinical and radiological information analysed the CT and DSA in consensus. ResultsA total of 22 patients were included in the study. CT angiography correctly classified 15 of the 16 cases of AVM measuring less than 3cm (93.75% sensitivity). All cases of deep venous drainage and all those located in eloquent areas were correctly detected (100% sensitivity). The presence of any type of aneurysm related with the AVM was detected in 13 of 15 cases (86.6% sensitivity); 7 of 9 of the intranidal aneurysms were detected (77.78% sensitivity), as were 6 of the 9 flow aneurysms (66.67% sensitivity). ConclusionCT angiography is highly sensitive in the characterisation of cerebral AVMs measuring less than 3cm, of those located in eloquent areas, and of those with deep venous drainage; it is also highly sensitive in detecting aneurysms related with AVMs. However, CT angiography is less sensitive in detecting intranidal and flow aneurysms related with AVMs.

Biologically effective dose and prediction of obliteration of unruptured arteriovenous malformations treated by upfront Gamma Knife radiosurgery: a series of 149 consecutive cases.

Arteriovenous malformations (AVMs) present no pathologic tissue, and radiation dose is confined in a clear targeted volume. The authors retrospectively evaluated the role of the biologically effective dose (BED) after Gamma Knife radiosurgery (GKRS) for brain AVMs. A total of 149 consecutive cases of unruptured AVMs treated by upfront GKRS in Lille University Hospital, France, were included. The mean length of follow-up was 52.9 months (median 48, range 12-154 months). The primary outcome was obliteration, and the secondary outcome was complication appearance. The marginal dose was 24 Gy in a vast majority of cases (n = 115, 77.2%; range 18-25 Gy). The mean BED was 220.1 Gy2.47 (median 229.9, range 106.7-246.8 Gy2.47). The mean beam-on time was 32.3 minutes (median 30.8, range 9-138.7 minutes). In the present series, the mean radiation dose rate was 2.259 Gy/min (median 2.176, range 1.313-3.665 Gy/min). The Virginia score was 0 in 29 (19.5%), 1 in 61 (40.9%), 2 in 41 (27.5%), 3 in 18 (12.1%), and 4 in 0 (0%) patients, respectively. The mean Pollock-Flickinger score was 1.11 (median 1.52, range 0.4-2.9). Univariate (for obliteration and complication appearance) and multivariate (for obliteration only) analyses were performed. A total of 104 AVMs (69.8%) were obliterated at the last follow-up. The strongest predictor for obliteration was BED (p = 0.03). A radiosurgical obliteration score is proposed, derived from a fitted multivariable model: (0.018 × BED) + (1.58 × V12) + (-0.013689 × beam-on time) + (0.021 × age) - 4.38. The area under the receiver operating characteristic curve was 0.7438; after internal validation using bootstrap methods, it was 0.7088. No statistically significant relationship between radiation dose rate and obliteration was found (p = 0.29). Twenty-eight (18.8%) patients developed complications after GKRS; 20 (13.4%) of these patients had transient adverse radiological effects (perilesional edema developed). Predictors for complication appearance were higher prescription isodose volume (p = 0.005) and 12-Gy isodose line volume (V12; p = 0.001), higher Pollock-Flickinger (p = 0.02) and Virginia scores (p = 0.003), and lower beam-on time (p = 0.03). The BED was the strongest predictor of obliteration of unruptured AVMs after upfront GKRS. A radiosurgical score comprising the BED is proposed. The V12 appears as a predictor for both efficacy and toxicity. Beam-on time was illustrated as statistically significant for both obliteration and complication appearance. The radiation dose rate did not influence obliteration in the current analysis. The exact BED threshold remains to be established by further studies.

Perioperative management of arteriovenous malformation guided by integrated evaluation of hemodynamics.

We aimed to demonstrate the value of monitoring infants with arteriovenous malformation (AVM) during endovascular embolization with integrated evaluation of hemodynamics (IEH) and guiding decisions according to the underlying pathophysiology. This is a retrospective analysis of the perioperative hemodynamics data for 2 complex cases of AVM transferred to Khaula Hospital in Oman for interventional management. We described the value of novel physiological insights gained from comprehensive IEH and provided a systematic approach to the perioperative management. Postoperative targeted neonatal echo (TNE) was used to guide the weaning of the cardiovascular medications within 24h. Both cases showed significant right ventricle (RV) volume overload before surgery. Narrowing of the pulse pressure (PP) during or after endovascular embolization was used as a marker of compromised systemic blood flow in real time followed by an assessment by TNE to guide the appropriate therapy.Conclusion: Integrated evaluation of hemodynamics is helpful to guide perioperative physiologic-based management of AVM. What is Known: • The preoperative management of hemodynamic compromise due to AVM has been described in many articles. • Perioperative management of AVM and related hemodynamics is a challenge to the intensive care team. What is New: • Integrated evaluation of hemodynamics is a comprehensive assessment and helpful in understanding the underlying physiologic changes during intervention with AVM. • This integrated evaluation can lead to physiologic-based medical recommendation with subsequent improvement.

Arteriovenous Malformation of the Lip: A Rare Case Report

Vascular malformation (VM) consists of a group of tumors that emerge from vascular origin caused by vascular angiovascular or lymphoproliferation. Arteriovenous malformations (AVMs) contribute high-flow, creating direct vein artery contact without regular capillary network. AVMs are present at birth or in congenital. Acquired AVMs occur later in life due to hormonal changes or trauma, and acquired AVMs in oral cavity are very rare. AVMs are persistent and progressive in nature when present, can represent a lethal, causing significant blood loss, and an incomplete resection frequently leads to a recurrence of the lesion. We present a rare case of a congenital AVM diagnosed on retinue dental checkup using color doppler ultrasonography (USG) in a 62-year-old man from South India.

A case of small intestinal arteriovenous malformation that was difficult to diagnose despite multiple endoscopies

A case of small intestinal arteriovenous malformation that was difficult to diagnose despite multiple endoscopies

S-shaped distal access catheter supported microcatheter navigation into the lenticulostriate artery feeders of brain arteriovenous malformations.

Although the embolization of lenticulostriate artery feeders is often warranted in the treatment of brain arteriovenous malformations, it is technically challenging due to steep and repeated angulations. Here, we describe our novel technique of navigating a flow-guided microcatheter into lenticulostriate artery feeders using the strong support provided by an S-shaped distal access catheter. We reviewed our retrospective cohort of brain arteriovenous malformations, in which lenticulostriate artery feeders were attempted to embolize. During the study period, endovascular embolization was performed in 25 arteriovenous malformations cases. Of these, eight lenticulostriate artery feeders were present in six cases (24%). In two cases, lenticulostriate artery feeder catheterization was avoided from the beginning due to the small diameters of the feeders. After all, microcatheter navigation for lenticulostriate artery feeders were attempted in four cases with six lenticulostriate artery feeders. In all the six feeders, the S-shaped distal access catheter was successful in supporting the microcatheter to advance distally to the lenticulostriate artery feeders, even if other approaches were unsuccessful. Of the six catheterized lenticulostriate artery feeders, four were embolized. Symptomatic infarction in the lenticulostriate artery territory and mild vasospasm occurred in two cases each, but they did not result in permanent neurological deficits. Although some potential complications need to be considered, the S-shaped distal access catheter technique appears to be an effective alternative approach to gaining access to difficult feeders of arteriovenous malformations.

Pediatric intracranial arteriovenous malformations: Examining rehabilitation outcomes.

Arteriovenous malformation (AVM) rupture in children can cause debilitating neurological injury. Rehabilitation is key to recovery, though literature details little regarding rehabilitation outcomes. We examined a single-center experience with pediatric AVMs as related to acute inpatient rehabilitation outcomes. At our institution, a retrospective chart review was completed examining all cases of intracranial AVMs in patients age 18 and younger who completed our acute inpatient rehabilitation program between 2012-2018. Patient characteristics, clinical data, treatment modality, and functional outcomes were reviewed. 14 patients with AVMs underwent acute inpatient rehabilitation; nine (64.3%) treated surgically at our institution, two (14.3%) non-surgically at our institution, and three (21.4%) surgically at an outside facility prior to transitioning care at our institution. Eight (57.1%) were male, seven (50.0%) Caucasian, and seven (50.0%) Hispanic. Seven (50.0%) presented with AVM rupture; six (42.9%) were found incidentally on imaging. Clinical courses, treatment outcomes, and post-treatment complications varied. Several patients underwent repeat treatment or additional procedures. Neurological deficits identified included hemiparesis, dystonia, spasticity, epilepsy, hydrocephalus, and ataxia. Inpatient rehabilitation unit length of stay was on average 21 days (SD 9.02, range 9-41). Functional Independence Measure for Children (WeeFIM®) scores, including self-care, mobility, and cognition, demonstrated improvement upon discharge. The mean total change was 36.7 points in those treated surgically, 16.5 in those treated non-surgically, and 25.7 in those treated surgically at another facility. We found that all pediatric patients with intracranial AVMs, across all treatment modalities, demonstrated improved outcomes across all functional domains after an acute inpatient rehabilitation program.

Prenatal diagnosis and treatment of intrahepatic arteriovenous fistulas: case reports and the literature review

Background Congenital arteriovenous intrahepatic fistulas, which are hepatic hemangiomas and arteriovenous malformations (AVMs) are rare and they confused with each other. Knowledge of prenatal medical treatment of AVMs is insufficient. Objectives First is to emphasize the distinction between hepatic hemangioma and AVMs. Second is discussion of the first case of hepatic AVM that responded well to steroid-propranolol treatment in the prenatal period. Methods Color Doppler ultrasonography, fetal and postnatal MR were used for diagnosis. Results The first case is a giant hepatic hemangioma diagnosed and progressively growing in the prenatal period and gradually shrinking in the postnatal period. The second case was hepatic AVM with no signs of heart failure during the prenatal period and postnatal right extended hepatectomy was performed as the anastomosis was enlarged and intraportal collateral vessels were developed. The third case is the first hepatic AVM which reaches a term that was prenatally diagnosed and responded to treatment with marked reduction. Conclusion Color flow and pulse Doppler imaging have a key role in the prenatal diagnosis of arteriovenous fistulas. Intrahepatic AVM are abnormal intrahepatic vascular network formation primarily fed by the hepatic artery or its branches and drained by the hepatic venous system. This vascular region looks like a mass, but it does not contain a solid area, which allows the separation of hepatic AVMs from hepatic hemangiomas. Steroid and propranolol therapy should be considered in management.