Case Studies Series: Cerebellar AVM

This child was 10 years old when he initially presented to the hospital.  He was with his grandmother when he began complaining of a headache, after which he lost consciousness. His grandmother called the paramedics but the sheriff got to the house first.  The sheriff found the child not only unresponsive but also not breathing. According to the sheriff, he was purple. He initiated CPR and was able to get his pulse back. The sheriff saved him!

He was brought into the emergency room and was intubated.  He had a CT scan of the brain that showed an intracranial hemorrhage.  During the time in the ER, he arrested again and was brought back.

The ER called me after the CT scan on the way up to the Pediatric ICU.

I met him and his family in the ICU.

His CT head showed blood in the cerebellum with compression of the brain stem. There was also some hydrocephalus. His CT angiogram showed an associated arteriovenous malformation that had caused the hemorrhage.

I spoke to his parents about his condition and was pessimistic because he had stopped breathing and his heart had stopped pumping several times. I was worried he had sustained a global injury to the brain due to lack of blood flow and oxygen.  His exam was also consistent with a lack of oxygen/blood flow to the brain – he appeared encephalopathic rather than just comatose.

He was very unstable hemodynamically and part of that was related to the pressure on the brain stem, part on the hydrocephalus, and part was due to the multiple cardiac arrests.

We discussed how to proceed.  I was not sure surgery would help him but I did think he would need a decompression of the brain stem.  I told the family that surgery was very risky because he may arrest again on the OR table which may be life-threatening. Since we will be operating on him from the back of the head and he will be face down, if he does arrest we wouldn’t be able to fully perform a resuscitation.

I still felt it was the right thing to do.  We all decided to go ahead with surgery.

He was taken to the OR and had a craniotomy for evacuation of the hemorrhage and at the same time resection of the AVM.

We were able to resect the entire AVM.

Amazingly, my pessimism was completely unfounded! He not only improved – he recovered back to his baseline and is now living a normal life.

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