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Large Arteriovenous Malformation in an Adolescent Presenting With First Seizure

Jennifer L. McKinney, MD
JAMA Neurol. 2013;70(6):798. doi:10.1001/jamaneurol.2013.1945.
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A 16-year-old previously healthy male had a generalized seizure. In the emergency department, he was combative, requiring administration of lorazepam and haloperidol. A noncontrast computed tomographic scan of the head (Figure 1) was suspicious for a large vascular malformation involving the left temporal, parietal, and occipital lobes. The neurological examination was significant for impaired word repetition ability and truncal ataxia without dysmetria or dysdiadokinesia. The ataxia resolved over 24 hours and was assumed to be secondary to medications. The young man's brain magnetic resonance imaging revealed a large arteriovenous malformation (AVM) involving the aforementioned lobes with arterial supply from the left middle cerebral artery and the left posterior cerebral artery (Figure 2). The consultant neurosurgeon indicated that the lesion was not amenable to surgical treatment owing to almost complete involvement of the left hemisphere and the lesion's dual supply from the anterior and posterior circulations. The patient was prescribed antiepilepsy medication and has remained seizure free 18 months out.

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Figure 1. Noncontrast head computed tomographic scan. There are multiple irregular structures involving the posterior aspect of the left lateral ventricle. Also, there are multiple cortical calcifications involving the left temporal, parietal, and occipital lobes (arrows). There is significant cortical and white matter atrophy of the involved tissues.

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Figure 2. Axial T2-weighted brain magnetic resonance image. A, Arteriovenous malformation involving the left temporal, occipital, and parietal lobes associated with severe atrophy. B, Venous drainage is primarily in the superior sagittal sinus and vein of Galen, with reciprocal enlargement of the straight, right transverse, and right sigmoid sinuses (arrow).

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