News on the AVM Front.

Not mine....

Childhood Stroke Causes
Many children who have strokes experience them from unknown causes. There are some known causes of Childhood Stroke; they include the following things.
Antiphospholipid Antibody Syndrome: Antiphospholipid Antibody Syndrome is a result of Antiphospholipid Antibodies. Antibodies are usually produced by the immune system in order to fight foreign substances in the body, such as viruses and bacteria. At times, the body will recognize it's own cells as a foreign substance and the immune system will attempt to fight them. When a child has Antiphospholipid Antibody Syndrome, their body both recognizes and attempts to fight a part of their cell's membrane known as, 'Phospholipids,' as being foreign substances, producing antibodies to work against them.
MELAS Syndrome: MELAS Syndrome is a part of a group of muscular disorder and is rare. It occurs due to a defect in genetic material causing a portion of the cell's structure to release energy, resulting in disease of the muscles and brain. Symptoms of MELAS Syndrome include recurrent, stroke-like episodes involving headaches, followed by seizures and vomiting. Muscle weakness in one side of the body, and accumulation of lactic acid in the blood are additional symptoms. The child may have a noticeably short stature as well. The child may experience visual disturbances including either impaired vision or blindness in one half of their field of vision known as, 'Hemianopasia.' The child may experience complete blindness caused by lesions on the brain related to vision; a condition referred to as, 'Cortical Blindness.' The causes of MELAS Syndrome are not understood, although research has found that it does run in families.
Sickle Cell Anemia: Sickle Cell Anemia is a disease which causes red blood cells to produce abnormal hemoglobin, the portion of the blood that carries oxygen throughout the body. There are various forms of Sickle Cell Disease; some are mild, others are more serious. Sickle Cell Anemia is caused by Hemoglobin, 'S,' which is an abnormal type of Hemoglobin. A person inherits the disease from both of their parents, who carry Hemoglobin S.
Vasculitis: Vasculitis involves an inflammation in the blood vessel system. It affects arteries, veins and capillaries of any size or type, and in any location. Vasculitis has the potential to cause dysfunctions in any organ system in the body, to include the Peripheral Nervous Systems. Symptoms a person will experience depend on which blood vessels and organs have been affected. Vasculitis is something that is capable of occurring with other disorders, such as Temporal Arteritis.
Temporal Arteritis: Temporal Arteritis, also referred to as, 'Giant Cell Arteritis,' or, 'Cranial Arteritis,' involves an inflammation of the temporal artery. The temporal artery follows a path over the temple and beside the eye. There are several symptoms associated with Temporal Arteritis, to include muscle pain, pain when chewing, fever, stiffness, and tenderness in the temple area. Other symptoms of Temporal Arteritis include weight loss, anemia, shaking, fatigue, sweats, and vision loss.
Disseminated Intravascular Coagulation: Disseminated Intravascular Coagulation is something that happens when a person's blood clotting mechanisms are activated throughout the entire body, instead of remaining localized to just an area which has been injured.
Embolus: An, 'Embolus,' is a clot which has formed at the location of a blockage, or in a place in the arterial tree, and then broken off and carried into the blood flow through smaller vessels where it then blocks one. Many times, an Embolus will form in the heart or a larger artery which leads away from it, and then travel to the brain or another organ.
Factor 'V' Leiden: Factor 'V' Leiden involves a phenomenon referred to as, 'APCR,' where a genetic mutation in the Factor V gene then produces a change in the Factor V protein. The result is that the protein then becomes resistant to inactivation by another protein; protein C.
Moyamoya Disease: Moyamoya Disease is a disease that affects blood vessels in the brain. Moyamoya disease is progressive, and is marked by the narrowing or closing of the main artery to the brain, causing paralysis in the person's upper extremities, legs, and feet. Symptoms of Moyamoya disease include psychiatric problems, mental retardation, vision problems, and headaches.
Illegal Drug Use: There is an increase in the percentage of childhood strokes in adolescent populations connected to illegal drug use. Both Hemorrhagic and Ischemic types of strokes have increased, and the most common illegal drugs involved include crack cocaine and smoked amphetamines, such as methamphetamines. Injected forms of illegal drugs are also responsible for an increase in strokes in this population.
Brain Infections
Encephalitis: There are various types of Encephalitis, which involves an inflammation of the brain; most are caused by a viral infection. Meningitis can be caused by several different forms of bacteria; viral Meningitis is usually limited to ten days or less. There are many symptoms of Encephalitis, including a sudden fever, vomiting, headache, sensitivity to light, confusion, irritability, confusion, clumsiness, stiff neck and back, and an unsteady gait. The following symptoms require immediate medical attention; poor responsiveness, loss of consciousness, seizures, muscle weakness, memory loss, sudden severe dementia, impaired judgment, and a withdrawal from social interaction.
Meningitis: Meningitis involves an infection of the membranes surrounding the spinal cord and brain. Symptoms of Meningitis can show up very suddenly. These symptoms include a serious and persistent headache, a high fever, nausea, vomiting, and a stiff neck. Emergency treatment may be needed for symptoms such as sleepiness, confusion, and difficulty waking up.
Arteriovenous Malformation (AVM): AVM is a congenital disorder which is characterized by complex, tangled webbing of veins and arteries.
Polycythemia: Polycythemia involves an overproduction of blood cells, causing a thickening of the child's blood. Polycythemia increases the blood's clotting tendency, as well as its viscosity.
Disorder Which Cause Blood Clotting: Disorders that cause blood clotting may lead to the potential for the child to experience a stroke.
Premature Birth: Premature Birth is considered to occur when a baby is born three weeks or more prior to the due date expected.
An Injury at Birth: Injuries which occur at birth have the potential to damage the brain and increase the risk of a stroke.
Chicken Pox: Chicken Pox, in extreme cases, has been found to be one cause of strokes in children.
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Stroke of Bad Luck in the Senate
As if any of you residents or med students need this, StopPagingMe.com would like to remind you that your health is precious and this case of a bright, active, generally healthy Senator form South Dakota, helps to remind us of that.Senator Tim Johnson (D) of South Dakota was conducting a conference call yesterday with reporters when he began stuttering and according to the Associated Press report, became somewhat incoherent. He recovered enough to ask if there were any additional questions but “appeared ill” to his staffers - ill enough to rush him to George Washington University Hospital. (When they heard a VIP politician was coming, as I’m sure they are pre-warned of political emergencies such as these, how many of them thought Cheney was on the way again?)
Shortly after the conference call, spokesperson Julianne Fisher said he was undergoing evaluation for stroke-like symptoms.Upon arrival to the ED, it’s likely that he was sent directly for CT or angio (or both) to rule out intracranial bleed and/or stroke. In the meantime, their stroke team was activated as there has been a push in the medical world to more aggressively address acute cerebrovascular events. Many hospitals, particularly large academic tertiary centers have established stroke teams with fancy names like GWU’s “Brain Attack Team”.StopPagingMe.com’s physicians were obviously not in the radiology bullpen when the image came across but what they saw impressed them enough to take him for “emergent surgery,” according to numerous reports. [We wonder whether it was the resident who first viewed the shots and how quickly he called his attending? Pretty damn quickly we would guess.]Sometimes when media reports “surgery” they do not differentiate between interventional procedures and open surgical intervention, so we were skeptical that perhaps they found an aneurysm that could be coiled or a thrombus that could be lysed.However, the AP stated that doctors had to “drain blood from the brain” which implies a surgical evacuation to relieve pressure. Thus, the images most likely showed fresh blood with a midline shift and urgent need to relieve the pressure and stop further bleeding and permanent damage to cerebral architecture.Following the surgery Senator Johnson is most likely recovering in the neuro ICU with very close attention paid to intracranial pressures and further bleeding episodes. This will be a very telling few days for the politician and his family as his mental status and recovery prognosis will come into focus. But until he can be removed from sedation and off the tube (ventilator) very little can be assessed besides brain stem reflexes and electroencephalgographic (EEG) findings (which will be blunted by sedation).On the educational tip, an anteriovenous malformation (AVM) is a cluster of congenital arteriovenous communications without intervening capillaries. The arteries and veins are tortuous and dilated and they are more commonly supratentorial, occuring in the parietal lobe, middle cerebral, posterior cerebral, and anterior cerebral territories in decreasing frequencies. Only about 10% of them are infratentorial, i.e. cerebellar and below.Here are the cold hard numbers with regard to AVMs: In an unruptured AVM, the incidence of first bleed and the annual re-bleed is about 4%. The annual mortality rate due to an AVM is 1%, with the mortality at the first bleed being 10%. In patients presenting with a bleed, the possibility of recurrence was 25% in the next four years, and that of a third bleed is 25%within one year of the second episode.Studies suggest that only 34% of patients with AVM remained symptom free; 26% become symptomatic and partially disabled; 11% are severely disabled. Hemorrhage is the most common presentation with an incidence of about 70%. Unlike an aneurysm, AVMs bleed, more frequently during sleep and are unrelated to stress, trauma, or hypertension.
Digital angiography is still the imaging mode of choice. A detailed study of the arterial feeders, the nidus and venous drainage is mandatory.
Surgery remains the gold standard. Other modalities are considered only if a safe surgical excision without any long-lasting morbidity is not feasible. If possible, surgery is usually delayed for a few weeks (as the rebleed risk is much less unlike in aneurysms) unless the hematoma requires emergency evacuation.
Worthy links:
www.thamburaj.com/cerebral_AVMs.htm - Nice summary
http://neurosurgery.mgh.harvard.edu/neurovascular/ - Nice images
http://www.brain-surgery.com/bsicavm.html - Sweet video of the procedure
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And that's that.... I would give you something of me... but I'm at a computer at work... so I have to make it short.