Case 2 History ---- This patient was a 62 year old woman who had a known history of an untreatable, large AVM in the right parieto-occipital region. In January 2005 she suffered a subarachnoid hemorrhage (SAH) and was admitted to the Neuro ICU. A cerebral angiogram at this time revealed a large right parieto-occipital AVM, measuring 4.7 cm and fed by contributions from the anterior, middle and posterior cerebral arteries with evidence of superficial and deep venous drainage. Also noted was a 1 cm fusiform distal basilar artery aneurysm, and small aneurysms (5 mm or less) involving the right ophthalmic artery, right superior cerebellar artery, left superior cerebellar artery, and right PCA. The patient recovered from the SAH, with relatively little residual neurological deficit. However, in October 10/13 she sustained an AVM rupture with extensive intra-ventricular hemorrhage and SAH in the right sylvian fissure. She developed hydrocephalus and required placement of a right frontal ventriculostomy. Repeat cerebral angiogram was relatively unchanged compared to the prior exam; however, it was presumed that the AVM had bled. The patient remained largely comatose, although she had intact brainstem reflexes and was managed in the ICU. Due to suboptimal EVD placement and poor resolution of hydrocephalus, the EVD was withdrawn and replaced on 10/17. Apparently, on 10/18, the patient experienced re-bleeding and markedly worsened clinically. Her exam showed loss of some brainstem reflexes. Eventually, a decision was made by family to withdraw care and the patient died.
