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Case 275

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Female, 13 yo, had sudden signs of headache, nausea, vomit and fever 3 days prior. It evolved with signs of meningeal irritation and was taken to the PA two days after the clinical signs, where antibiotic therapy (ceftriaxone and acyclovir) was started empirically. She was transferred to the Emergency Department and an image test (brain computed tomography - Image 1) was requested. It showed lesion compatible with hemorrhagic encephalic stroke (hES) in knee topography of the corpus callosum.

Based on the clinical history and images provided, what is the most likely diagnosis?

a) Ruptured pericallosal artery aneurysm

25%

b) Arteriovenous malformation (AVM)

25%

c) Cavernoma

25%

d) Brain capillary telangectasias

25%
   

Image Analysis

Image 1: Computed tomography of the brain, without intravenous injection of iodinated contrast, axial cut, internal capsule level and core of the base. Presence of spontaneously hyperdense material, with density of blood (circled in red), in topography of the knee of the corpus callosum, compatible with recent bleeding.

 

 

Image 2: Cerebral arteriography from the internal carotid artery, seen in profile. Presence of a small arteriovenous malformation (AVM; circled in yellow) in the pericalosa artery (continuation of anterior cerebral aureus that surrounds the corpus callosum).

 

 

Image 3: 3D angio-MRI (time-of-flight) (3D TOF), which promotes contrast between vascular structures with flow and stationary tissue, in a single acquisition. Presence of hypersignal in knee topography of the corpus callosum corresponding to the small hematoma(in blue), visualized at CT (Image 1) as hyperdensity at the same location. MAV evidenced in cerebral arteriography is not identified.

 

Highlights

- AVMs are the main etiology of hemorrhagic stroke in children and adolescents;

- AVMs are congenital lesions and the risk of bleeding and other clinical manifestations depends on their size, location, and vascular and blood flow characteristics;

- CT, because of its greater availability, is the exam of choice for initial investigation in patients with suspected stroke, allowing good distinction between hemorrhagic and ischemic stroke;

- Angiography is the gold standard exam for the diagnosis of AVMs and, in case of intervention, for planning the surgical approach;

- The choice between expectant and interventional management, as well as the treatment modality, should be individualized and require analysis of the anatomical and physiological characteristics of the lesion.

 

References

- Osborn AG, Salzman KL, Jhaveri MD. Diagnostic imaging- Brain; 3rd ed. Elsevier 2016.
- Rooper AH, Samuels MA, Klein JP. Adams and Victor's Principles of Neurology; 10th ed. McGraw-Hill 2014.
- Solomon RA, Connolly ES, Jr. Arteriovenous Malformations of the Brain. N Engl J Med. 2017;376(19):1859-66.
- Trujillo Osvaldo, Nogales-Gaete Jorge, Sáez David. Trombosis venosa cerebral aislada. Rev. méd. Chile  2008 136( 7 ): 946-948.
- Jain R, Robertson PL, Gandhi D, Gujar SK, Muraszko KM, Gebarski S. Radiation-Induced Cavernomas of the Brain.  2005 AJNR Am J Neuroradiol 26:1158–1162.
- Robert J Singer, Christopher S Ogilvy, Guy Rordorf- Brain arteriovenous malformations. UpToDate 2017. Available in: https://www.uptodate.com/contents/brain-arteriovenous-malformations. Accessed in: 05/10/2017.

 

Author

Eduardo José Paolinelli Vaz de Oliveira, 5th year medical student at Universidade Federal de Minas Gerais

E-mail: eduardopaolinelli[at]gmail.com

 

Supervisor

Alexandre Varella Giannetti, neurosurgeon at the Hospital das Clínicas/UFMG and Adjunct Professor at the Department of Surgery of UFMG Medical School.

E-mail: agjg[at]terra.com.br

 

Reviewers

Laio Paiva,Lucas Bruno Rezende, Thiago Heringer, André Naback, Professora Viviane Parisotto e Professor José Nelson

 

Translated by

Lucas José Resende, 5th year medical student at Universidade Federal de Minas Gerais.

Email: lucasresende.ufmg [at]gmail.com

Test question

(HC-FMUSP) Hemorrhagic Vascular Brain Accident is a medical emergency and its diagnosis should be performed as soon as possible. What is the most appropriate test to define the diagnosis?

a) Magnetic Resonance

25%

b) Electroencephalogram

25%

c) Electroneuromyography

25%

d) Videoelectroencephalography

25%

e) Computed tomography

25%
   

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