1. ARTERIO-VENOUS MALFORMATION

2. Definition
 Arteriovenous
malformations (AVM)
of the brain and
spinal cord are
tangles of abnormal
blood vessels.They
can form wherever
arteries and veins
exist.

3. Causes
 The exact cause of arteriovenous
malformations is unknown.

4. Risks
 Family history—some types of arteriovenous
malformations are from genetic defects that can
be passed on from one generation to the next.
 History of bleeding—some types of
arteriovenous malformations are linked to an
increased risk of bleeding. People with
unexplained recurrent bleeding may be at higher
risk of having arteriovenous malformations.
 Smoking

5. Symptoms
 Seizures
 Headache, especially on one side of the head
 Muscle weakness
 Lightheadedness
 Loss of coordination, especially when walking
 Difficulty speaking or understanding language
 Loss of senses /Visual problems
 Memory loss
 Difficulty thinking or mental confusion
 Hallucinations

6. Diagnosis
 Angiography or arteriography
 Computed axial tomography (CT scan)
 Magnetic resonance imaging (MRI)
 Magnetic resonance angiogram (MRA)

7. Treatment
 Microsurgery
 Radiosurgery
 Endovascular (embolization)

8. Radiosurgery
 very successful at treating small to medium-
sized AVMs.
 Obliteration (destruction) rates for AVMs less
than 3 cm in diameter are about 80 to 85%.

9. Microsurgery

10. Endovascular Treatment
 Associated symptoms

11. Examination
 Vital signs
 Physical examination
 Neurologic Examination

12. Glasgow Coma Scale

13. ER Management
 ABCs of resuscitation
 IVF
 Blood glucose level
 Medical or structural cause?

14. Medical Cause
 Additional laboratory and radiologic tests
 Infectious
 Metabolic
 Toxicologic

15. Structural Cause
 Cranial CT scan
 Refer to neurosurgeon

16. Case Scenario
 Chief Complaint: vomiting and loose stools.
 History: fever, vomiting, irritable , (-) fall/trauma
 Physical Examination:
 drowsy, irritable, (+) seizure
 BP80/60 PR 130 RR 38 Temp 39oC CBG 40mg/dL
 soft-tissue contusion over the left scalp and ecchymosis
 Chest: clear breath sounds
 Abdomen: globular, hyperactive BS, soft, non tender,
(+)multiple 1- peso-like marks on the anterior abdomen
 Extremities are cool and mottled.

17. Additional Information
 History
 Bleeding tendencies
 Associated medical problems
 Neurologic Exam
 Pupils
 Funduscopic findings
 Motors: preferential movement
 Social History
 Caregiver
 Socio-economic status
 Educational attainment of parents/caregiver

18. DIAGNOSIS?

19. Differentials
Medical Structural
 Electrolyte abnormality
 Encephalopathy
 Infection (sepsis)
 Intussusception
 Meningitis and encephalitis
 Uremia (hemolytic-uremic
syndrome)
 Cerebral vascular accident
 Cerebral vein thrombosis
 Hydrocephalus
 Intracerebral tumor
 Subdural empyema
 Trauma (intracranial
hemorrhage, diffuse
cerebral swelling, shaken
baby syndrome)

20. Management
 Blood work-up
 Imaging
 Cranial CT scan
 Xrays

21. CHILD ABUSE

22. Shaken Baby Syndrome
 Definition: SBS is the vigorous manual
shaking of an infant who is being held by the
extremities or shoulders
 Whiplash-induced intracranial and intraocular
hemorrhage
 No external signs of head injury

23. Presenting Symptoms
 Frequently non-specific
 May be seen first in the outpatient setting
 URTI, vomiting, irritability (23%)
 Respiratory distress
 Diarrhea, poor feeding
 Lethargy/decreased level of consciousness
 Apnea, seizure, history of minor trauma

24. Symptoms
 History must match physical findings
 High index of suspicion when non-specific
symptoms and history are at odds

25. Signs on Physical Exam
 Retinal hemorrhage
 Bulging fontanel
 Pupillary changes
 Other physical injuries:
 Fractures, soft tissue injuries, bruises
 Mechanism of injury/history does not
coincide with presenting signs

26. Diagnosis
 CT scan – method of choice

27. Diagnosis
 Ophthalmologic consult
 Retinal hemorrhage (75-90%)
 Minimal external signs (one of the hallmarks
of SBS)
 Bulging fontanelle in 55% of infants with
subdural hematoma

28. Findings
The Brain
 Subdural hemorrhage
 Subarachnoid hemorrhage
 Diffuse axonal injury
 Edema/infarction
 Parenchymal contusion
 Parenchymal hemorrhage

29. The Eye
 Retinal hemorrhage
 Vitreous hemorrhage
 Papilledema
 Retinal detachment
 Disruption of eye contents

30. The Bones
 Rib fractures
 Skull fractures
 Long bone injuries:
 Periosteal stripping
 Metaphyseal fractures
 Shaft fractures

31. Prognosis
 Significant morbidity (50%) and
mortality (15%)

32. SBS Complications
 Developmental delays
 Behavioral problems
 Mental retardation
 Post-traumatic hydrocephalus, cerebral atrophy
 Permanent brain damage
 Seizures
 Paralysis
 Blindness
 Deafness

34. THANK YOU