Arteriovenous Malformation
Patient Presentation
C.F., a 55 year old male was playing soccer when he suddenly collapsed. He was intubated in the field for airway protection and brought to the closest ER where a head CT was immediately obtained. The scan showed a large ICH (intracranial hemorrhage). He was soon transferred to another facility for a higher level of care. Upon admission the patient was intubated but not sedated. He did not open his eyes and his pupils were 2mm and nonreactive to light. He did have a positive cough and gag reflex however he had no spontaneous movement of any extremities nor did he have any spontaneous breathing over the controlled ventilator rate. He had elevated cardiac enzymes but no other abnormal serum lab results.
Differential List
ICH (known), AVM (arteriovenous malformation), Aneurysm rupture
Diagnosis
Upon arrival to the new facility the patient was brought to interventional radiology where he underwent a cerebral angiogram which revealed a complex AVM that had ruptured. The patient did have a known history of hypertension however due to the rupture of the AVM it was deducted that he was most likely not compliant with medications.
Treatment
There they were able to partially embolize the malformation however due to the critical state and poor neurological exam of the patient, he was then brought immediately to the operating room for a left decompressive hemicraniectomy and EVD placement for ICP monitoring. Following his surgery he was brought back to the ICU for monitoring where his neurological exam and ICP was examined every hour while in the ICU. His blood pressure was closely monitored, with a goal of a systolic blood pressure less than 130mmHg to prevent rebleeding in his brain. It was well controlled with labetalol 200mg PO BID, lisinopril 20mg PO daily, hydrochlorothiazide 25mg PO daily and Norvasc® 10mg PO daily. Within two weeks the patient was able to have his EVD removed, however he was not able to be weaned from the ventilator immediately following surgery so he received a tracheostomy and a PEG tube. Gradually over the next three weeks the patient began weakly moving all of his extremities however he was neither speaking nor following commands consistently. Physical therapy, occupation therapy, and speech language pathologists worked closely with the patient until he was considered ready to go to a sub-acute rehabilitation facility.
Outcomes
Five months after the patient was initially discharged he was readmitted to his treating facility where he underwent an AVM resection and cranioplasty (replacing his previously removed skull). Following this operation he was brought back to interventional radiology where a follow up cerebral angiogram showed complete AVM resection. The patient was discharged to home three days later. Prior to this last admission and when he was discharged the patient was AAOx3, was moving all of his extremities with good strength and even said he was slowly starting to play soccer again. He also claimed to be compliant with all medications for his hypertension, hyperlipidemia and gastric reflux.