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Multiple Dural Arte Rio Venous Malformations Coming From The
Multiple Dural Arte Rio Venous Malformations Coming From The
Multiple Dural Arte Rio Venous Malformations Coming From The
• Chief Complaint:
Disorientation
History of Present Illness
1 year PTA
limping imbalance
2 months PTA
Wide Memory Irritability/ Decreased
headache low
based gait lapses attention libido
Consult
Past Medical History
Epidural
hematoma
due to trauma
Craniectomy
3 years ago
Personal/ Social History
• Non- smoker
• Occasional Alcoholic beverage drinker
• History of marijuana and cough syrup intake
in his early 20’s.
• Salesman/ Farm Manager
• Stevedore
Family History
• Cerebrovascular Accident
• Hypertension
Review of System
Skin: (-) lesion, brown hair
Lymph node: (-) lymphadenopathy
Bones, Joints and Muscle: (-) fractures, (-)
dislocations (-) swelling
Head: (+) headache, (-) seizure
Eyes: (-) blurring of vision, (-) discharges
Ears: (-) deafness, (-) discharge, (-) pain
Review of System
Nose: (-) discharge, (-) epistaxis
Neck: (-) enlarge lymph nodes
Respiratory: (-) cough, (-) dyspnea
Cardiovascular: (-) chest pain, (-) exertional
dyspnea, (-) orthopnea
Gastrointestinal: (-) diarrhea, (-) nausea, (-)
vomiting
Review of System
• Nervous System:
(-) photophobia,(-) blurring of vision,
(-) limitation in motion of neck
• Allergies: None
Physical Examinations
• Gen Survey: awake, conscious, coherent, ambulatory, not
in CR distress
abulic speech
failed
Cranial 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 (-) (-)
• CN III,IV, VI: intact extraocular muscle
• CN V: (+) corneal reflex
(+) can clench teeth
• CN VII: (-) facial asymmetry, wrinkling of the
forehead 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
R L
R L
motor sensory
++ ++
++ ++
DTR
• Nuchal rigidity(-)
• Brudzinski: (-)
• Kernigs: (-)
• Babinski: (-)
• Coordination:
No tremors
Can button his shirt and write word legibly
Slight loss of balance when allowed to stand
without support
Finger to nose: Normal
• Rapid Alternating Movement: can pronate and
supinate the hand, however slowing when ask
to change the direction
Diagnostics
• CBC: Normal ECG: Sinus Rhythm
• Crea: 85.20
• Na: 151.00
• K: 4.0
• 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)
Salient Features
Multiple Cerebral
Aneurysms Cavernous
Malformations
Salient 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)
Cranial nerves: intact
Motor: 4/5 on both the upper & lower ext
Tendency to fall to the right
Mild dysdiadochokinesia
Negative meningeal signs
Multiple Cerebral Arteriovenous
Malformations
• Rare: 0.3- 4.9% of all AVMS
• 1.84% had multiple AVM
• Dural AVMS: 10-14% of AVMS
• Female Preponderance
•• 5 th
to 6 th
5 to 6 Decade
th th Decade 48 years old
•• Left sided preponderance
Left sided preponderance
Bilateral arteries
Dural AVMs
• nosoligically heterogenous group of lesions
linked by similar architecture
• Results to sinus thrombosis – 72%
• May also precede their appearance
Symptoms and Signs:
• Signs and Symptoms*** location of the
• Memory impairment- 6-12% lesion
Progesssive•memory impairment- 6-12%
Focal neurodeficits- 5-14%
• Headache – 43-50%
• Bruits/ timmitus- 67-92%
In our patient…
• Cognitive impairment
Anterior cerebral arteries involvement
Result to:
ABULIA
PARAPLEGIA
• Tests:
MMSE~ 22/30: mild cognitive impairment
Clock drawing test: minor deviations
GPCOG: cognitive impairment
Clinical Dementia Rating- Mild Dementia
Dural AVMs
• Course : BENIGN
• Treatment:
~expectant observation to more involved
multimodality treatment interventions such as both
transarterial and transvenous embolization.
• IN our PATIENT:
Memantin ~ 16th week of medication
No signs of progression of the symptoms
Conclusion
• Multiple Dural AV Malformations present
according to their anatomical location
Disorientation and memory lapses~ ACA territory
Common manifestations with unsual diagnosis
• AVMs- 0.3%-4.9% had multiple involvements
Conclusion
• After extensive research
• NO PUBLISHED INFORMATION ON
INVOLVEMENT OF ALL 3 BRANCHES
OF THE BILATERAL ANTERIOR
CEREBRAL ARTERIES
1 ST
CASE
GOOD DAY!!!!