Presentation is loading. Please wait.

Presentation is loading. Please wait.

AVMs of the Posterior Fossa Case Presentation and Literature Discussion Christopher Showers Columbia University College of Physicians and Surgeons.

Similar presentations


Presentation on theme: "AVMs of the Posterior Fossa Case Presentation and Literature Discussion Christopher Showers Columbia University College of Physicians and Surgeons."— Presentation transcript:

1 AVMs of the Posterior Fossa Case Presentation and Literature Discussion Christopher Showers Columbia University College of Physicians and Surgeons

2 Patient CP - HPI USH eating dinner  sudden onset very severe R H/A with lightheadedness, nausea Progressive lethargy  LOC en route to CCH Upon Arrivals: Decorticate Posturing  Intubated; CT head acquired Emergent R Frontal EVD  transfer MGH

3 Outside H-CT 8/14/13 21:13

4 Patient CP - MGH Exam: – Intubated, sedated, no follow commands – L anisocoria (4/3mm)  nonreactive b/l, (-)corneals, (-)OCR, (+)cough, flexion RUE, TF in LLE – GCS: 4-5 Labs: Na 123; K 5.7 Drips: Mannitol x1; 23% NaCl x2  3% NaCl EVD: at 0, open  no drainage Repeat CT Head: interval mild progression of hemorrhage, hydrocephalus

5 Patient CP PMx: L Humoral fracture 1.5wk ago Meds: ASA 81mg qD; Duloxetine 60mg qD ROS: L arm pain; no complaints prior SHx: retired teacher, nonsmoker, active at b/l FHx: no sudden bleeds

6 Preop Angio 8/15/13 08:30 Right Vertebral Injections

7 Operative Resection SMG  2-3 (1-2S, 1E, 0V) SOC  evacuation of hemorrhage / resection of AVM; placement of R occipital EVD – Washout of subdural blood – Ligated feeding arteries, identified abnormal superior vein draining AVM – Another nidus identified  anterior superior, not visualized on angio

8 Intraop Angio 8/15/13 17:02 Right Vertebral Injections

9 Operative Resection x2 Rentered initial craniectomy site – Wider area of dissection  extensive & diffuse abnormal vessels draining into large vein extending superiorly – Skeletonized large vein with generous R cerebellar resection  Witnessed to turn blue NICU

10 Post-op H-CT 8/15/13 21:38

11 Post-op Exam Pupils symmetric, reactive 3  2mm b/l No OCR, vertical bobbing Mild cough reflex UE: withdraw to pain b/l LE: TF b/l Deteriorated to extensor posturing UE/LE b/l Expired on 8/21/13 01:35am

12 Posterior Fossa AVMs 7.5% - 20.0% of all intracranial AVMs (da Costa 2009; Drake 1986; Perret 1966) – 72.4% Cerebellar / 21.5% Brainstem (da Costa 2009) Vermian most common (Sampson 2004) – Arterial Input  distal SCA & distal PICA b/l – Large or involving 4 th V  deep AICA feeders – Venous Drainage  Superiorly to Galenic System

13 Greater Rate of Hemorrhage in PF-AVMs – Hemorrhage as presenting symptoms  ~90% vs. 29-54% in ST (Khaw 2004; Stefani 2002; Drake 1986; Solomon 1986) – Smaller size vs. ST  increased hemorrhage risk (Drake 1986; Sampson 1986; Kader 1994; Langer 1998) – Greater Rate of AA  25% vs. 5-8% in ST (Sampson 1997; Lanzino 1999) – Bleeds more frequent and FATAL  up to 66.7% (Fults and Kelly 1984; Batjer 2009; Symon 1995 – Rebleeding in 6.0% - 17.8%, 34.3% Dw/DD (Mast 1997; Stapf 2006; Steinberg 2008) 5-6% annual risk up to 5 years (Halim 2004) vs. 3-4% ST (Baskaya 2006) Presentation of PF-AVMs

14 Rarely present with Seizure – 2/68 (2.9%)  attribute to hydrocephalus (Yasargil 1998) General Neuro deficits / CN palsy  up to 28% (Batjer 2009; Stahl 1980) – Mass effect – Ischemia – steal phenomenon – Hydrocephalus – CN V palsy Presentation of PF-AVMs

15 Treatment Optimal to defer surgical resection 4 – 6 wks after initial hemorrhage and clot evacuation – Not possible w/ Life threatening bleed – 53 pf-AVMs  15 emergent operation, AVM removed at time of evaluation in all (Sampson 2004) Preoperative Embolization  recommended – Occlude small feeders difficult to locate surgically Caution occluding large vessels proximally – Great Benefit in Brainstem AVMs – Mortality 1.3% ; Severe-Mod AE 6.7%, 15.3% (Wikholm 1966)

16 Radiosurgery  GKRS – Small, unruptured, eloquence, elderly (Ciurea, 2010) – Latency of obliteration after treatment  no abatement of risk in that time (Ciurea 2010) – GKRS  Obliteration: 63% 2y; 73% 3y - 95% stable neurologically (Massager 2000) Multimodal Therapy  recommended (Steinberg 2008) – SMG III-IV, mostly brainstem AVM – XRT alone  residual AVM on f/u Treatment

17 General Outcomes Excellent to Good outcomes  71.0% - 82.1% Poor morbid outcome  13.0% - 22% Mortality  3.6% - 16.7% (Solomon 1986, Samson 1986; Symon 1995; Drake 1986; Steinberg 2008)

18 Outcome Associations 12 pf-AVM w/ hemorrhage (Yilmaz 2011) – Worse w/ initial mRS, SMG grade, hematoma size 59 pf-AVM w/ hemorrhage (van Loon 1993) – Worse w/ degree of 4 th V compression, GCS 98 pf-AVM – 61/98 (62.2%) w/ Hemorrhage (da Costa 2009) – Worse w/ presence of AA, initial mRS, # of treatments 48 pf-AVM  SMG III-IV (Steinberg 2008) – 37/48 (77.1%) w/ Hemorrhage; mean f/u 4.8y – Multimodal therapy >> XRT alone

19 Acknowledgments CP&S – Dr. Jeffrey Bruce – Dr. Donald Quest – SD Andrew Chan – SD Brian Gill MGH – Dr. William Butler – Dr. Patrick Codd – Dr. Chris Stapelton – Dr. Peter Fecci

20 NOTES BELOW HERE

21 Posterior Fossa AVMs da Costa 2009 – 106 / 678 (15.6%) 72.4% Cerebellar / 21.5% Brainstem Cooperative Study of Intracranial Aneurysms and SAH (Perret 1966) – 32/453  7% Drake 1986 – 116/600  20% Vermian most common (Sampson 2004) – Arterial Input  distal SCA & distal PICA b/l – Large or involving 4 th V  deep AICA feeders – Venous Drainage  Superiorly to Galenic System

22 Hemorrhage in PF-AVMs Brugge, 2010 – 61/98 (62.3%) presented with Intracranial hemorrhage – Hemorrhage  reduced mRS at presentation (p=0.0229) though not final mRS (p=0.41) – AA, poor initial mRS, treatment  reduced final mRS – 52 f/u imaging  48.9% completelly obliterated 13.4% smaller but patent nidus 9.6% uchanged – 10/61 hemorrhaged in f/u  4.1% risk/year No difference in treated vs. untreated

23


Download ppt "AVMs of the Posterior Fossa Case Presentation and Literature Discussion Christopher Showers Columbia University College of Physicians and Surgeons."

Similar presentations


Ads by Google