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How to plan for specific scenarios
Published in Vivian A. Elwell, Ramez Kirollos, Syed Al-Haddad, Neurosurgery, 2014
Vivian A. Elwell, Ramez Kirollos, Syed Al-Haddad
Focus on safety. Surgery may not be recommended until a further episode of haemorrhage to allow for a gliotic plane to develop. Mention the specific factors, including location within the pons and the characteristics of the haemorrhage (e.g. whether the bleed presents to the cortical surface or is surrounded by functional neural tissue). Without prompting by the examiner, mention that any associated developmental venous anomaly (DVA) should remain untouched.
Neuroimaging
Published in John W. Scadding, Nicholas A. Losseff, Clinical Neurology, 2011
Cavernomas are angiographically occult. They are often colocated with a developmental venous anomaly (DVA or ‘venous angioma’). This variant in venous anatomy consists of a caput of vessels that converge on a single vein draining towards a normal venous sinus. They are not a pathological malformation in their own right. Although an associated cavernoma could cause symptoms, the DVA itself is asymptomatic and ligation would cause a venous infarct. A DVA can usually be diagnosed on routine MRI but, if in doubt, the characteristic arrangement of veins is clearly seen following contrast enhancement. DSA is not required to make this diagnosis.
Emergency surgery for brainstem cavernoma haemorrhage with severe neurological presentation. Is it indicated and worthwhile?
Published in British Journal of Neurosurgery, 2020
Cristiano M. Antunes, Renata S. F. Marques, Maria J. S. Machado, Leandro T. M. Marques, Miguel A. R. Filipe, João S. Fernandes, Carlos M. G. Alegria
This 66-year-old female was diagnosed with a brainstem haemorrhage on head CT after the development of sudden onset headaches, gait imbalance, dysarthria, rotatory vertigo, nausea and vomiting. She was initially managed ‘conservatively’ being admitted in the Stroke Unit. MRI (Figure 6(a)) showed a bulbar haemorrhage associated with a cavernoma without an associated developmental venous anomaly. She remained stable for nine days. She then developed sudden ventilatory arrest and became unresponsive – GCS 4. Head CT was repeated and showed a re-bleed (Figure 6(b)). She was operated emergently through a midline suboccipital craniotomy with hematoma evacuation and complete cavernoma malformation excision through the caudal IV ventricle floor in the midline. Postoperative MRI confirmed gross total cavernoma excision (Figure 6(c)). The patient was then admitted to the ICU. She soon recovered to a GCS 15 but required a tracheostomy for a short period. She continued to improve and underwent a rehabilitation program and was left with residual ataxia and right-side dysmetria. During the last follow-up, she was able to perform self-care activities and returned to work – mRankin 1.
Angiographic Findings in the Tolosa–Hunt Syndrome and Resolution after Corticosteroid Treatment
Published in Neuro-Ophthalmology, 2018
Krishnan Ravindran, Philip Schmalz, Nurhan Torun, Michael Ronthal, Yu-Ming Chang, Ajith J. Thomas
A 26-year-old otherwise healthy woman presented with right sided headaches and associated right retrobulbar discomfort, with onset 2 weeks prior to presentation. She had a longstanding history of intermittent, throbbing left-sided headaches with accompanying mild nausea or vomiting, but this was a new headache. She then developed diplopia which progressed to complete oculomotor nerve palsy in the right eye over the course of 2 days. She denied any ocular trauma, recent illness, viral syndrome, fevers, chills, and other constitutional complaints. Past medical history was notable for left parietal sinus pericranii treated in childhood with staged bleomycin sclerotherapy and a history of a left cerebellar developmental venous anomaly. There was no history of ocular surgery. Family history was notable for an indirect carotid-cavernous fistula in her father treated with transvenous coil embolization.