Case 23 History ---- The patient was a 71 year old man with a history of hypertension and a right cerebellopontine angle tumor who presented with acute onset of neck pain at 2:00 AM with diaphoresis and loss of consciousness for 20 minutes. He was taken to the ER where he was found to be somnolent but arousable to loud voice or sternal rub. Brainstem cranial nerve and descending tracts were intact. A head CT was obtained which showed a small amount of subarachnoid blood in the ambient, prepontine, and interpeduncular cisterns with hydrocephalus involving the lateral ventricles and third ventricle with dilation of the temporal horns. He was then admitted to the NNICU with a subarachnoid hemorrhage and received a ventriculostomy placed through the right frontal lobe into the lateral ventricle. He underwent a cerebral angiogram which revealed an AVM in the right cerebellopontine angle. The AVM was fed by an enlarged right anterior inferior cerebellar artery and two enlarged brainstem perforating vessels. He clinically improved with ventriculostomy. He was scheduled to undergo resection of the AVM, however, on he suddenly became unresponsive with increased intracranial pressure. The ICP spontaneously resolved to normal; however, he then suddenly became unresponsive again with no movement of his extremities and again with an elevated ICP. CT scan was obtained which showed diffuse subarachnoid blood in the posterior fossa with blood clot in the right cerebellopontine angle, the lateral right cerebellum, right pons and midbrain. His neurologic exam at that time was noted to be consistent with clinical brain death. Supportive care was discontinued. (Angiograms and radiographs were not available for this old case; however, the vascular malformation was unequivocal.)
