DELAYED DIAGNOSIS OF AVM PRESENTING WITH STROKE AND SEIZURES IN A YOUNG NIGERIAN: A CASE REPORT

Abstract

Background: Brain arteriovenous malformations (BAVM) are a cause of intracerebral haemorrhage (ICH) and seizures especially in young patients. ICH due to BAVMs seem to have relatively better neurologic outcomes compared to other causes of spontaneous ICH as patients often recover fully. In this report we highlight a case of delayed diagnosis of BAVM in a young man who presented with seizures and stroke.

Case summary: A 36-year-old man was referred on account of focal, secondarily generalized tonic clonic convulsions. He had suffered a right ICH 3 years before the index presentation. His general physical and neurologic examination were normal. Electroencephalography revealed right sided focal epileptiform discharges and brain MRI revealed a right parieto-occipital AVM. The seizures were controlled with carbamazepine and he was referred for neurosurgical evaluation.

Conclusion: BAVMs are an important cause of intracerebral haemorrhage and attendant neurologic morbidity especially in young individuals. Neuroimaging plays a central role in BAVM diagnosis and MRI is of great value where facilities and expertise for conventional angiography do not exist. In some instances, delayed presentation of BAVM cases may be due to relatively better neurologic outcomes in BAVM-related ICH.

Figure 1:

Electroencephalogram showing epileptiform sharp and slow waves predominantly in the right temporal and parieto-occipital derivations (red boxes).

Figure 2:

Axial FLAIR, and sagittal T2-weighted images showing multiple, serpiginous signal-void areas, giving the so-called “bag of worm” appearance in the right parieto-occipital region. Surrounding hyperintensities represent gliotic changes. Dilatation of the posterior horn of the right lateral ventricle is seen in the sagittal image.

Figure 3:

Time of flight MRA showing feeding artery (an opercular branch of the right middle cerebral artery) and the draining parietal veins which empty into the superior sagittal sinus via the right superficial cerebral vein.