Multiple Dural Arteriovenous Malformations

Coming from the

Three Branches of the Anterior Cerebral Arteries
 The Patient
• 48 year old, Male
• A stevedore

• 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

• Vital Signs: BP=120/80; CR-84;T=37; RR=18

• HEENT: pink palpebral conjunctiva, anicteric sclera, (-)

tonsillo pharyngeal congestion, (-) CLAD (-) bruit

• Precordium: adynamic, PMI at 5th ICSMCL,

(-) murmur, (-) heaves
 Physical Examination
CHEST: equal chest expansion, clear breath
sounds, (-) retraction, (-) lagging

Abdomen: flat, soft, NABS, non tender, (-)

organomegaly

Extremities: full equal pulses, (-) edema

 Neurologic Examination
• Mental Status Exam:
Medium built, fairly groomed

abulic speech

Good eye contact

Depressed Mood
Flat affect

Oriented to person, place time and situation

 Mini Mental Status Exam
Maxim Patient’s
um Score Questions
Score
5 4 “What is the year? Season? Date? Day of the week? Month?”
5 5 “Where are we now: State? County? Town/city? Hospital? Floor?”
3 3 The examiner names three unrelated objects clearly and slowly, then
asks the patient to name all three of them. The patient’s response is
used for scoring. The examiner repeats them until patient learns all of
them, if possible. Number of trials: ___________
5 2 I would like you to count backward from 100 by sevens.” (93, 86, 79,
72, 65, …) Stop after five answers.
Alternative: “Spell WORLD backwards.” (D-L-R-O-W)
3 1 “Earlier I told you the names of three things. Can you tell me what those
were?
2 2 Show the patient two simple objects, such as a wristwatch and a
pencil,
and ask the patient to name them.
1 0 “Repeat the phrase: ‘No ifs, ands, or buts.’”
3 3 “Take the paper in your right hand, fold it in half, and put it on the
floor.”
(The examiner gives the patient a piece of blank paper.)
1 1 “Please read this and do what it says.” (Written instruction is “Close
your eyes.”)
1 1 Make up and write a sentence about anything.” (This sentence must
contain a noun and a verb.)
1 0 “Please copy this picture.” (The examiner gives the patient a blank
piece of paper and asks him/her to draw the symbol below. All 10
angles must be present and two must intersect.)
• Mini Mental Status Examination:
22

• Clock Drawing test was 3

• GPCOG Screening Test Score of 3
• Clinical Dementia Rating of 1

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

5/5 4/5 100% 100%

5/5 4/5 100% 100%

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

• Chest Xray: Normal

 Ct SCAN
Plain Contrast
AP View-1- Right AP view -2-Right

`4 Vessel Angiogram: AV MAL

 Angiography
Lateral View -1 Lateral View -2
 angiography
AP View- 1-Left Ap view -2-left
 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)
 Salient Features

• Cranial nerves: intact

• Motor: 4/5 on both the upper & lower ext
• Tendency to fall to the right
• Mild dysdiadochokinesia
• Negative meningeal signs
 Differential Diagnosis
Multiple Emboli:
1. Cardiac
Intracranial
2. Infectious origin
Hemorrhage

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!!!!