Case 8 History ---- This patient was a 61 year old woman who was first diagnosed with an AVM in the posterior fossa at the age of 22 when she developed an intracranial hemorrhage and recovered without surgery, but with residual slurred speech and poor coordination. She later had a second small intracranial hemorrhage from which she also made a good recovery, without any new neurologic deficits. An angiogram at that time showed a large midline AVM in the posterior fossa with bilateral cerebellar involvement. Arterial supply to the AVM was from the AICA, PICA and superior cerebellar artery. Prior to neurosurgery, the patient developed worsening dysarthria, ataxia, and lethargy and was admitted to an outside hospital with a new intracranial bleed. The next day she underwent emergency ventricular peritoneal shunt placement and showed rapid deterioration progressing to obtundation requiring mechanical ventilation. She was then admitted to BJH. There was limitation of extraocular movements. She was admitted to the NeuroICU with a persistent left sixth cranial nerve palsy, disorientation and inappropriate antidiuretic hormone secretion with her sodium falling as low as 126 which responded gradually to treatment with fluid restriction, hypertonic saline and demiclocycline. On the sixth hospital day she developed low grade fever and a left lower lobe infiltrate for which ceftazidime and vancomycin were begun. Clindamycin was begun for aspiration pneumonia with gradually deteriorating oxygenation status. On the fourteenth hospital day she was reintubated and placed back on mechanical ventilation for decreased oxygenation associated with a temperature spike and a period of hypertension. Her antibiotic coverage was extended to Gentamycin and Aztreonam. A chest X-ray continued to show a left lower lobe infiltrate and an abdominal CT showed bilateral adrenal hemorrhages. She became hypotensive and was begun on dopamine and given stress doses of steroids. During placement of a central venous line she became bradycardic and ultimately asystolic. Resuscitative attempts were unsuccessful.
