Medical Image of the Month: Large Complex Cerebral Arteriovenous Malformation

Figure 1. Computed tomography angiography of the head showing the large complex arteriovenous malformation near the midline of the brain. A: sagittal plane the malformation is fed predominantly by the anterior circulation more on the right and the left. B: coronal plane.

A 70-year-old woman with a history of hypertension presented with left-sided weakness, headache, nausea, and vomiting. She denied loss of consciousness or seizure activity. On examination, she had receptive aphasia. Pupils were equal, round and reactive. She had neck pain on flexion. Her left upper extremity was plegic. Computed tomography of the brain showed acute hemorrhage involving the right thalamus, extending into the ventricular system, and a midline mass. She underwent a computed tomography angiogram, which showed a large, complex arteriovenous malformation (AVM) with a dilated branch of the right suprasellar internal carotid artery feeding the AVM, which then drained into the vein of Galen and straight sinus (Figure 1). She was monitored in the intensive care unit without worsening neurological deficit. She was discharged to a rehabilitation facility, having had no intravascular or surgical intervention.

AVMs are intracranial vascular anomalies which occur in 0.1% of the population (1). Clinical presentations include intracranial hemorrhage, seizures, headaches and neurological deficits, with hemorrhage being the most common and significant manifestation (2). The gold standard imaging modality is conventional cerebral angiography (1). Treating an AVM is a challenging clinical problem, as the risk of treatment has to be weighed against the natural history of the condition. Treatment modalities include observation with medical management, surgical resection, stereotactic radiosurgery, and endovascular embolization (1,2).

Vedhapriya Srinivasan MD, Piruthiviraj Natarajan MD, Reuben De Almeida, Safal Shetty MD, and Kulothungan Gunasekaran MD.

Bridgeport Hospital

Yale New Haven Health

New Haven, CT USA

References

1. Ajiboye N, Chalouhi N, Starke RM, Zanaty M, Bell R. Cerebral arteriovenous malformations: evaluation and management. ScientificWorldJournal 2014;2014:649036. [CrossRef] [PubMed]
2. Geibprasert S, Pongpech S, Jiarakongmun P, Shroff MM, Armstrong DC, Krings T. Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. RadioGraphics. 2010;30:483-501. [CrossRef] [PubMed]

Cite as: Srinivasan V, Natarajan P, De Almeida R, Shetty S, Gunasekaran K. Medical image of the month: large complex cerebral arteriovenous malformation. Southwest J Pulm Crit Care. 2019;19(3):97-8. doi: https://doi.org/10.13175/swjpcc027-19 PDF 

August 2019 Imaging Case of the Month: A 51-Year-Old Man with a Headache

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 51-year-old previously healthy man presented with complaints of increasing headache frequency and severity. The patient noted headaches in the past, but that the frequency of these headaches, which he referred to as “migraines,” had been increasing in recent months. The patient does note some auras with the headaches.

The patient reported a history of pneumonia in the past, but denied recurrent pneumonias. The only medication the patient takes was ibuprofen, for his headaches; he denied allergies. The patient’s past surgical history was remarkable only for a right inguinal hernia repair, a right Achilles tendon injury repair, and surgical removal of a palpable left thigh mass, ultimately shown to represent scar tissue. The patient smoked 1-8 cigarettes / day for 35 years, quitting one year earlier.

The patient’s physical examination was remarkable for obesity (BMI= 30.4). His vital signs were within the normal range. A few reddish rounded spots were noted on his lower lip, but no other abnormalities were noted at physical examination.

Basic laboratory data, including a complete blood count, electrolyte panel, B12 and folate levels, a C-reactive protein level, and liver function studies were all within the normal range. Mild hypercholesterolemia was noted. An electrocardiogram revealed normal findings. As part of a routine office visit, frontal and lateral chest radiography (Figure 1) was performed.  

Figure 1. Frontal and lateral chest radiography

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of ten pages)

1. The chest radiograph shows circumscribed nodular opacities
2. The chest radiograph shows multifocal nodular pulmonary consolidation
3. The chest radiograph shows multiple, bilateral cavitary nodules
4. The chest radiograph shows multiple, bilateral small circumscribed nodules
5. The chest radiograph shows nodular interstitial thickening

Cite as: Gotway MB. August 2019 imaging case of the month: a 52-year-old man with a headache. Southwest J Pulm Crit Care. 2019;19(2):52-64. doi: https://doi.org/10.13175/swjpcc052-19 PDF 

Medical Image of the Week: Complex Arteriovenous Malformation

Figure 1. Initial chest radiograph demonstrating right mid lung field process.

Figure 2. Panel A: Contrast enhanced thoracic CT scan axial view demonstrating very large, complex AVM. Panel B: Sagittal view.

Figure 3. Chest radiograph after coil embolization.

A 62-year-old man presented to the emergency department complaining of shortness of breath with exertion and mild non-productive cough. The patient was afebrile and physical exam was remarkable only for scattered bilateral rhonchi. White blood cell count was 8,800 K/uL and hematocrit was 51.5%. Room air arterial blood gas (at 1520 meters altitude) was pH 7.41, pCO2 42 mm Hg, PO2 45 mm Hg, and O2 saturation 78%. D-dimer was normal at 0.36 ug/ml. Chest radiograph (Figure 1) demonstrated what was interpreted as a right-sided mid/lower lung field infiltrate. The patient was placed on high-flow supplemental oxygen and treatment was initiated with intravenous levofloxacin, methylprednisilone and nebulized beta-agonists. The patient’s oxygenation failed to improve over a period of several days, and a CAT of the chest (Figures 2) was obtained, which demonstrated a very large, right middle lobe, complex pulmonary arteriovenous malformation. The patient was referred to interventional radiology for catheter directed coil embolization (Figure 3). Following that procedure the patient’s oxygen requirement decreased from 15 l/m via nasal cannula to 3 l/m.

Pulmonary arteriovenous malformations (PAVM’s) are rare, with an incidence of 2-3 per 100,000, and are associated with hereditary hemorrhagic telangiectasia (HHT), in approximately 80% of cases (1). The intrapulmonary shunt associated with PAVM’s may result in significant hypoxemia, cerebrovascular accident or embolic brain abscess. The preferred screening tool is transthoracic contrast echocardiography, which demonstrates extra-cardiac shunt. Chest CT scan may be used to both confirm the diagnosis of PAVM and to define the vascular anatomy. Patients who meet three of the four Curacao criteria (epistaxis, family history, telangiectasia, and visceral lesions) are recognized as suffering from HHT (2). Catheter directed coil embolization is an effective and well-tolerated treatment method for PAVM; and generally results in reduced shunt fraction and improved oxygenation (3).

Kathleen Monahan and Charles J. VanHook MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous malformations. Chest. 2013 Sep;144(3):1033-44. [CrossRef] [PubMed]
2. Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet. 2000 Mar 6;91(1):66-7. [CrossRef] [PubMed]
3. Dutton JA, Jackson JE, Hughes JM, Whyte MK, Peters AM, Ussov W, Allison DJ.Pulmonary arteriovenous malformations: results of treatment with coil embolization in 53 patients. AJR Am J Roentgenol. 1995 Nov;165(5):1119-25. [CrossRef] [PubMed]

Cite as: Monahan K, VanHook CJ. Medical image of the week: complex arteriovenous malformation. Southwest J Pulm Crit Care. 2016 May;12(5):197-8. doi: http://dx.doi.org/10.13175/swjpcc027-16 PDF

October 2015 Imaging Case of the Month

Philip W. Ho, MD

Stacey Black, MD

Clinton Jokerst, MD

Department of Medical Imaging

Banner University Medical Center

Tucson, AZ

Clinical History: A 68-year old Hispanic man presented to the emergency department with dry cough for two days and was found to be hypoxic, with O₂ saturation in the high 80’s. The patient’s clinical history is significant for remote 3 year smoking history and former occupation as a miner. Frontal and lateral chest radiography (Figure 1) was obtained.

Figure 1. Frontal (panel A) and lateral (panel B) chest radiograph.

Based on the appearance of the chest radiograph, which of the following is the least likely diagnosis? (Click on the correct answer to proceed to the second of five panels)

1. Osteophyte
2. Peripheral nerve sheath tumor
3. Pneumonia
4. Pulmonary arteriovenous malformation (AVM)

Cite as: Ho PW, Black S, Jokerst C. October 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(4)144-50. doi: http://dx.doi.org/10.13175/swjpcc117-15 PDF 

Medical Image of the Week: Pulmonary Arteriovenous Malformations

Figure 1. Cardiac ultrasound showing right to left shunting.

Figure 2. Thoracic CT scan showing arteriovenous malformations (AVM's, arrows).

A 34 year old woman presented to the clinic with exertional dyspnea since childhood. Oxygen saturations in clinic were 92% on room air. On review of systems she admitted to recurrent epistaxis and her daughter also suffered from frequent epistaxis. Bubble contrast echocardiography showed severe right to left shunting without evidence of intracardiac shunt (Figure 1). Computed tomography angiogram of the chest revealed multiple bilateral arteriovenous malformations (AVM’s), the largest measuring 9mm on coronal images (Figure 2). MRI of the brain was negative for AVM’s. She was referred to interventional radiology for microcoil embolization. She met two of four Curaçao criteria for the diagnosis of hereditary hemorrhagic telangiectasia (HHT), giving her “possible HHT”. She was referred for genetic testing to confirm the diagnosis.

Chris Strawter MD and Laura Meinke MD

University of Arizona

Tucson, Arizona

References

1. Lacombe P, Lacout A, Marcy PY, et al. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging. 2013;94:835-48. [CrossRef] [PubMed]
2. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158:643-61. [CrossRef] [PubMed]
3. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011;48:73-87. [CrossRef] [PubMed]

Reference as: Strawter C, Meinke L. Medical image of the week: pulmonary arteriovenous malformations. Southwest J Pulm Crit Care. 2014;9(4):238-9. doi: http://dx.doi.org/10.13175/swjpcc131-14 PDF