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RESUMEN Las malformaciones arteriovenosas cerebrales son anormalidades vasculares caracterizadas por una conexión fistulosa entre arterias y venas sin la intervención del lecho capilar normalmente existente. Se localizan con frecuencia en el territorio de las grandes arterias cerebrales, pero pueden aparecer en cualquier otro lecho vascular y son las causantes de hemorragias intracerebrales, epilepsia, signos neurológicos focales y otros síntomas. Se reporta el caso de una paciente de sexo femenino, de 64 años, hipertensa y diabética, que de forma aguda presenta cuadro de debilidad hemicorporal izquierda. Al examen físico presentaba, disartria, hemiparesia izquierda y signos meníngeos. La tomografía axial computarizada inicial mostró un hematoma intraparenquimatoso parietooccipital derecho con apertura al sistema ventricular. La angio-TAC mostró malformaciones arteriovenosas cerebrales parietooccipitales derechas. El tratamiento de este padecimiento depende de los factores del paciente, así como de factores angiográficos. Las diferentes opciones son: conducta expectante, tratamiento médico sintomático, resección quirúrgica, terapia endovascular, radiocirugía estereotáxica. Se presenta el caso clínico de un hematoma intraparenquimatoso secundario a una malformación arteriovenosa cerebral porque es un padecimiento poco frecuente en un adulto mayor.

ABSTRACT Cerebral arteriovenous malformations are vascular abnormalities characterized by a fistulous connection between arteries and veins without the intervention of the normally existing capillary bed. They are frequently located in the territory of the great cerebral arteries, but they can appear in any other vascular bed and are causes of intracerebral hemorrhages, epilepsy, focal neurological signs, and other symptoms. A case of a 64-year-old female patient, hypertensive and diabetic, who acutely presented with left hemicorporal weakness, is presented. On physical examination, she had dysarthria, left hemiparesis and meningeal signs. The initial computed tomography scan showed a right parietooccipital intraparenchymal hematoma opening to the ventricular system. CT angiography showed right parietooccipital cerebral arteriovenous malformations. Treatment of this condition depends on patient factors, as well as angiographic factors. The different options are: watchful waiting, symptomatic medical treatment, surgical resection, endovascular therapy, stereotaxic radiosurgery. The clinical case of an intraparenchymal hematoma secondary to a cerebral arteriovenous malformation is presented because it is a rare condition in an older adult.

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BACKGROUND: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States. METHODS: Using the National Inpatient Sample, the largest all-payer inpatient care database within the United States, we isolated patients who were admitted on an elective basis for cAVM treatment and determined the treatment modality undergone by these patients. The cohort was dichotomized separately at 2 ARUBA time points: the European Stroke Conference presentation in May 2013, and The Lancet publication in February 2014. RESULTS: We found that the overall treatment rate of unruptured cAVMs decreased after both time points. However, the rate of surgical excision alone, relative to other modalities, was significantly increased, and endovascular intervention demonstrated a nonsignificant decrease. CONCLUSIONS: Our findings suggest that the ARUBA trial has influenced unruptured cAVM treatment patterns within the United States. Although the overall treatment rate has decreased, unruptured cAVMs, when treated post-ARUBA, are most commonly approached with surgical excision alone.

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BACKGROUND: Whether cerebral arteriovenous malformations (AVMs) should be treated remains an ongoing debate. Nevertheless, there is a need for predictive factors that assist in labelling lesions as low or high risk for future rupture. Our aim was to design a new classification that would consider hemodynamic and anatomic factors in the rapid assessment of rupture risk in patients with AVMs. METHODS: This was a retrospective study that included 639 patients with ruptured and unruptured AVMs. We proposed a new classification score (1-4 points) for AVM rupture risk using three factors: feeding artery mean velocity (Vm), nidus size, and type of venous drainage. We employed descriptive statistics and logistic regression analysis. RESULTS: A total of 639 patients with cerebral AVMs, 388 (60%) had unruptured AVMs and 251 (40%) had ruptured AVMs. Logistic regression analysis revealed a significant effect of Vm, nidus size, and venous drainage type in accounting for the variability of rupture odds (P = 0.0001, R2 = 0.437) for patients with AVMs. Based in the odds ratios, grades 1 and 2 of the proposed classification were corresponded to low risk of hemorrhage, while grades 3 and 4 were associated with hemorrhage: 1 point OR = (0.107 95% CI; 0.061-0.188), 2 point OR = (0.227 95% CI; 0.153-0.338), 3 point OR = (3.292 95% CI; 2.325-4.661), and 4 point OR = (23.304 95% CI; 11.077-49.027). CONCLUSION: This classification is useful and easy to use, and it may allow for the individualisation of each cerebral AVM and the assessment of rupture risk based on a model of categorisation.

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Introducción: Los aneurismas asociados a malformaciones arteriovenosas (MAV) son lesiones vasculares que suelen encontrarse hasta en el 15% de los casos, incrementando el riesgo global de hemorragia. La conducta frente a los aneurismas asociados es dicotómica en la literatura, mientras existen reportes de la desaparición de los mismos luego de la exéresis de la MAV, otros artículos enfatizan su tratamiento precoz. El síndrome del acento extranjero es un raro trastorno neurológico en el que el paciente habla su lengua materna como lo haría una persona extranjera y suena con “acento” extranjero a oídos de los oyentes nativos. Objetivo: Presentar un paciente que desarrolla el síndrome del acento extranjero posterior a la exéresis de una MAV y la evolución de un aneurisma asociado. Presentación de caso: Paciente pediátrico que luego de la exéresis de una MAV fronto-opercular posterior izquierda remite por completo un aneurisma de hiperflujo asociado, presentando en el postquirúrgico el síndrome del acento extranjero.Conclusión: Queda reportado el caso de este raro síndrome y la resolución espontánea de un aneurisma proximal luego de la exéresis de una MAV.

Introduction: The aneurysms associated with arteriovenous malformations (AVM) are vascular lesions that are usually found in up to 15% of cases, increasing the overall risk of bleeding. The behavior against associated aneurysms is dichotomous while there are reports of the disappearance of the same after the removal of the AVM, other items emphasize early treatment. Foreign accent syndrome is a rare neurological disorder in which the patient speaks his mother language as you would a foreigner and sounds with foreign "accent" to native listeners.Objective: To report a patient who developed foreign accent syndrome after excision of an AVM and the evolution of an associated aneurysm.Case presentation: pediatric patient that after a resection of fronto-opercular AVM refers back completely on an aneurysm associated hyper flow, presenting postsurgical foreign accent syndrome.Conclusion: the case of this rare syndrome and spontaneous resolution of a proximal aneurysm after excision of an AVM is hereby reported.

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