Treatment of scalp arteriovenous malformation

We report seven patients with scalp arteriovenous malformations, including two patients with lesions > 10 cm in diameter, who were successfully treated. The principal complaint of each patient was a deforming mass. Each of four patients had a history of blunt traumatic injury. The lesions, each consisting of the nidus, feeders, and draining veins, evolved in all patients. The nidus consisted of fistulae, which exhibited various angioarchitectures as revealed by angiography. A hemangiomatous component was histologically recognized in one patient. In five patients, in whom the lesions were relatively small and whose nidi included only large fistulae, the malformations were remedied by surgical intervention alone or were cured with embolization alone using liquid adhesives. In the two patients with lesions > 10 cm, the nidi consisted of numerous large fistulae and plexiform fistulae in one patient and plexiform fistulae and a hemangiomatous component in the other patient. These patients were treated with a combination of transarterial embolization and surgical intervention. Preoperative embolization greatly reduced blood loss during resection. Total excision and scalp reconstruction using a soft tissue expander were performed in both patients. The cosmetic results were excellent in all of the patients, and no recurrence has been recognized during the follow-up period, which ranges from 31 to 99 months. The treatment of scalp arteriovenous malformations should strive to improve deforming features and to attain a permanent cure. Because each nidus includes a variety of anomalous angioarchitectural features, there should be different means and a combination of treatments for each patient. Embolization alone could be adequate treatment in relatively small lesions, the nidi of which consist only of several large fistulae. For malformations with more extensive, large fistulae or with anomalous components other than large fistulae, a combined endovascular and surgical approach and scalp reconstruction seems to be the best treatment.     

Pulmonary arteriovenous malformation in the neonate

Pulmonary arteriovenous malformation (AVM) is a congenital condition, but because the symptoms usually do not occur until middle age, the diagnosis is often delayed. The authors report on a neonate, diagnosed at 2 weeks of age, who was treated by lobectomy at 35 months of age. This prompted a review of the diagnosis, pathophysiology, and treatment of pulmonary AVM. In the literature there are approximately 500 cases of pulmonary AVM. Special attention is given to the reports involving children. Eight cases have been reported in which the diagnosis was made in the first year of life. In two series, a chest roentgenogram showed abnormalities in all affected patients. Because of the strong association of pulmonary AVM with hereditary telangiectasia (Rendu-Osler-Weber syndrome), it is recommended that family members of affected patients be screened by chest roentgenograms for pulmonary AVM.     

Spontaneous disappearance of a renal arteriovenous malformation

We describe herein a case of complete spontaneous disappearance of a congenital arteriovenous malformation (AVM). A 28-year-old male was hospitalized for right flank pain and gross hematuria, followed by bladder tamponade. To improve the patient's symptoms, bladder irrigation was performed. Cystoscopy demonstrated bloody urine from the right ureteral orifice. Right selective renal arteriography demonstrated tortuous, coiled vascular channels with early filling of the renal vein. Thus, right renal AVM was diagnosed. However, the patient refused further treatment and was discharged. One year later, massive hematuria recurred with bladder tamponade and the patient was rehospitalized. Renal arteriography did not show any evidence of AVM and there has been no hematuria since.     

Endovascular treatment of an external carotid arteriovenous malformation

Herein we describe a case of a hemorrhagic adrenal pseudocyst that had been initially suspected as being a renal adenocarcinoma. The intraoperative anatomopathological study of the specimen permitted performing conservative surgery. The diagnosis and pathogenesis of this uncommon disease entity are discussed.     

Coexistence of schizencephaly and intracranial arteriovenous malformation in an infant

A 9-month-old infant had unilateral closed-lip schizencephaly in the right parietal lobe, which coexisted with an arteriovenous malformation in the nearby temporal area. Cranial MR showed a right parietal cleft lined with gray matter between the right lateral ventricle and the subarachnoid space, and cluster hypointensities throughout the right temporal lobe. Cerebral angiography revealed a right temporal arteriovenous malformation with feeding arteries arising from the right middle and posterior cerebral arteries and draining into the right sigmoid sinus via the engorged vein of Labbé.     

The value of peroperative colonic lavage in urgent colonic surgery. Apropos of 54 patients

The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. PATIENTS AND METHODS: Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. RESULTS: Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (< 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. CONCLUSION: This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure.     

Spontaneous disappearance of arteriovenous malformation during staged treatment of multiple cerebral arteriovenous malformations--case report

A 36-year-old male presented with aphasia and right hemiparesis due to the rupture of the larger of two arteriovenous malformations (AVMs) coexisting in the left hemisphere. The two AVMs had completely separate locations and different feeding arteries and draining systems. Two months after resection of the larger AVM and evacuation of the hematoma, carotid angiography showed the residual AVM had spontaneously disappeared. He was discharged without deficits. Change of cerebral hemodynamics after removal of the larger AVM presumably caused the spontaneous regression of the smaller one. Cerebral angiograms should be carefully examined because cerebral hemodynamics may be altered after removal of an AVM.     

Association of an intracranial arteriovenous malformation and a meningioma

A case of a simultaneously discovered arteriovenous malformation (AVM) and a meningioma is presented. A review of the literature revealed only four similar cases, but there have been 30 reports of other intracranial tumors in association with AVM. The possible mechanisms of this rare association are discussed.     

Diffuse pulmonary arteriovenous malformation in a child with polysplenia syndrome

Pulmonary arteriovenous malformation (PAVM) is usually seen as a well-circumscribed cystic mass. In this communication we describe a diffuse arteriovenous malformation in a 5-month-old infant. The lesion was seen only at the microscopic level and was associated with abdominal heterotaxy, atrial situs solitus, polysplenia, interrupted inferior vena cava, atrial septal defect, and atrioventricular canal. This uncommon association may be within the spectrum of polysplenia syndrome.     

Neuropsychological features of dementia due to dural arteriovenous malformation

We report two patients aged 65 and 61 years, who presented a subacute dementia with normal CT scan without contrast injection. Angiography showed a dural arteriovenous malformation. The patients improved dramatically with treatment of the malformation. Dementia was characterised by frontal dysfunction, emotional disorders, amnesic and praxic impairment. This neuropsychological pattern suggests a profile of global dementia in the field of vascular dementia.     

The value of preoperative planning for total hip arthroplasty

To analyse the value and accuracy of preoperative planning for total hip replacement (THR) we digitised electronically and compared the hand-sketched preoperative plans with the pre- and postoperative radiographs of 100 consecutive primary THRs. The correct type of prosthesis was planned in 98%; the agreement between planned and actually used components was 92% on the femoral side and 90% on the acetabular side. The mean (+/- SD) absolute difference between the planned and actual position of the centre of rotation of the hip was 2.5 +/- 1.1 mm vertically and 4.4 +/- 2.1 mm horizontally. On average, the inclination of the acetabular component differed by 7 +/- 2 degrees and anteversion by 9 +/- 3 degrees from the preoperative plans. The mean postoperative leg-length difference was 0.3 +/- 0.1 cm clinically and 0.2 +/- 0.1 cm radiologically. More than 80% of intraoperative difficulties were anticipated. Preoperative planning is of significant value for the successful performance of THR.     

Cost-effectiveness of preoperative localization studies in primary hyperparathyroid disease

OBJECTIVE: To evaluate the effect of preoperative localization studies on the surgical management of patients with primary hyperparathyroid disease (PHPT). SUMMARY BACKGROUND DATA: Reported cure rates of initial surgical exploration for PHPT are close to 95%. Preoperative localization studies are frequently obtained to improve surgical success and decrease operative time. METHODS: Initial cervical exploration was performed in 113 patients with PHPT from 1981 to 1993. Twenty-four patients (21%) had surgery without preoperative localization studies. The remaining 89 patients (79%) had 132 noninvasive preoperative localization studies. Success of the localization studies in tumor localization, pathologic findings, postoperative serum calcium levels, and operative times were compared. Patient costs of the studies were calculated. RESULTS: Disease was identified during operation in 23 of 24 patients (96%) having cervical exploration without preoperative localization studies, and they had normal calcium levels after surgery. Eighty-seven of 89 patients (98%) having preoperative localization studies were surgically cured. The highest sensitivity rate (60%) and highest positive predictive value (79%) of the localization studies were found with thallium-technetium scintiscanning. Average cost of the localization studies was $901 per patient. Combination studies were obtained in 32 patients at an average cost of $1,314 per patient without improving sensitivity. Mean operating time did not differ for localized and nonlocalized patients. CONCLUSIONS: Preoperative localization studies did not improve parathyroid localization or cure rate and did not substantially shorten operating time in initial cervical exploration for PHPT. The economic burden of routine preoperative localization studies in these patients is not justified.     

Relief of hemiballism from a basal ganglia arteriovenous malformation after radiosurgery

A patient with a 3-year history of progressive hemiballism presented with an unruptured arteriovenous malformation (AVM) in the contralateral caudate nucleus and putamen. PET demonstrated a matched reduction of cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) in the basal ganglia and adjacent frontal lobe. The patient underwent radiosurgery for the AVM. After a period of no clinical change for 6 months, the movement disorder resolved by month 7 post-treatment. The AVM was successfully obliterated 2 years after irradiation without any significant change in the regional CBF or CMRO2.     

Iron deficiency anemia caused by an arteriovenous malformation in the distal ileum

The case of a young woman with chronic iron deficiency anemia is described. Her consequent guaiac-positive stool suggested a gastrointestinal bleeding behind her anemia. The use of the conventional diagnostic techniques did not result in a definitive diagnosis. The source of the hemorrhage was later detected by the aid of selective mesenteric arteriography as an unusual form of arteriovenous malformations localized to the small intestine. 20 months passed since the resection of the affected intestinal segment. During this period of close follow up no clinical signs of recurrent gastrointestinal hemorrhage was observed. The authors briefly review the relevant literature.