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AVM, case 2

 

Clinical history
This 30-year-old full-term primigravida rapidly developed left arm paresis with paresthesias, followed a few hours later by left leg paresis. Emergency MRI was performed.

Neurological examination confirmed the profound left hand and arm paresis. Paresis of the left leg and severe gait impairment were also noted. Hyperreflexia of both arms and legs, especially on the left side, and a left Babinski sign were observed. McCormick III.

Emergency MRI (January 1995)
Images 1 - 2: Sagittal T1WI. Focal enlargement of the upper cervical spinal cord is seen, due to a well-delineated, although irregular, hypointense lesion. This appearance is strongly suggestive of a lesion containing dilated vascular components.
Images 3 - 7: Axial T1WI of the upper cervical cord and inferior posterior fossa. These images show that the lesion is restricted to the upper left part of the spinal cord. Again, dilated vessels can clearly be identified (see image 7).
Images 8 - 9: Axial T2WI. Confirm that the lesion is composed of vascular elements (flow void phenomenon).
An arteriovenous malformation was strongly suspected on basis of these images and complementary MR angiography was performed.

Video 1. MR Angiography

Follow-up clinical course
The patient underwent a Cesarean section, as normal delivery was considered to be too dangerous. In a few weeks time, the patient slowly recovered and three months later, the neurological deficits included minor weakness of the left arm only. Gait returned to normal. McCormick I.

Follow-up MRI (March 1995)
Images 10 - 12: Sagittal T1WI.
Images 13 - 17: Sagittal T2WI.
Images 18 - 24: Axial T1WI.
Images 25 - 29: Axial T2WI.
No major changes are observed as far as the size of the lesion is concerned. Associated edema is reduced and a small hyperintense focus is now seen within the lesion on the T1-weighted image (image 12), corresponding to a small hemorrhage.

These images were all taken at 1.5 T, on a new generation MR system, which allows better evaluation of the lesion, thanks to thinner slices, especially on the T2-weighted images.

Comment
Conventional angiography confirmed the final diagnosis of upper cervical AVM and an initial partial embolization was successful.

Search also:
- AVM, Dural fistulae

 

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