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1/208. Scrotal arteriovenous malformation and its preoperative embolization.

    arteriovenous malformations of the scrotum are extremely rare. A case of scrotal arteriovenous malformation and its preoperative embolization in a child is presented.
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2/208. Heart/single-lung transplant for a "failed Fontan" with pulmonary A-V malformation.

    Pulmonary arteriovenous malformation can occur in patients with functional single ventricle after a cavopulmonary connection. There is no effective medical treatment for this complication. Pulmonary arteriovenous malformations may regress over time after heart transplantation, but may be a source of significant perioperative morbidity. We report the case of a woman with single ventricle, ventricular dysfunction, and bilateral pulmonary arteriovenous malformations who had successful treatment of both cardiac and pulmonary failure with en bloc heart and right lung transplantation.
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3/208. Pancreatic arteriovenous malformation observed to bleed from the bile duct and a duodenal ulcer: report of a case.

    A 48-year-old man with recurrent episodes of biliary colic and subsequent pancreatitis was admitted to undergo a cholecystectomy. A gastroduodenal fiberscopic examination was performed because of massive melena on the seventh day after admission. It revealed a shallow ulcer on the posterior wall of a duodenal bulbus with rubor and an exposed vessel, which was clipped endoscopically to stop the bleeding. Further observations showed the papilla of Vater to be bleeding from the papilla. A contrast-enhanced abdominal computed tomography scan demonstrated a dilatation of the common bile duct and several dilated vasculatures around the portal vein, some of which drained into the portal vein. Based on the angiography findings, a diagnosis of arteriovenous malformation in the pancreas head was obtained and an embolization of the gastroduodenal artery was performed. Although the melena subsided, he underwent a pylorus-preserving pancreatoduodenectomy to prevent the recurrence of hemorrhaging. The histopathological findings of the bile duct revealed inflammatory cell infiltration and a detachment of the epithelium, except in a small part of the bile duct. A rupture of a damaged vessel inside the bile duct was observed, which was thought to be the cause of hemobilia. Sections of the pancreatic head demonstrated an inflammatory lesion with fibrosis and saponification as well as a large degree of arteriovenous anastomosis. The patient was discharged on the 35th day after the operation following an uneventful postoperative course.
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4/208. Metastatic cardiac angiosarcoma of the cervical spine. Case report.

    STUDY DESIGN: A case report of metastatic cardiac angiosarcoma of the cervical spine. OBJECTIVES: To show that this rare spine tumor behaves in the same manner as an arteriovenous malformation and embolization, which can allow for successful spine surgery, and to discuss the natural history and rarity of this tumor. SUMMARY OF BACKGROUND DATA: Primary angiosarcoma of the heart is a very rare tumor, with fewer than 200 reports in the English literature and nothing reported in the spine literature. RESULTS: The patient in this study initially sought treatment for neck pain, left arm pain, and weakness 17 months after cardiac surgery and subsequent chemotherapy. A cervical computed tomography scan demonstrated a C5 lytic vertebral body tumor with intracannilicular extension and cord compression. An anterior cervical approach was made, but the tumor was too vascular to resect, and surgery was aborted. The C5 vascular vertebral body metastasis subsequently was embolized successfully by an interventional neuroradiologist. reoperation via an anterior approach with corpectomy, cadaveric fibula, and anterior locking plate internal fixation was successful, producing marked improvement in the patients' symptoms. CONCLUSION: Spinal involvement by primary cardiac angiosarcoma is very rare, and this is only the second operative case ever reported. The vascular nature of this tumor makes it behave in a manner similar to that of a high-flow arteriovenous malformation. Surgery should not be undertaken before preoperative angiography and embolization. The dismal prognosis for this rare malignancy is discussed.
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5/208. Small-bowel investigation in occult gastrointestinal bleeding.

    Obscure gastrointestinal bleeding after careful endoscopy of the upper and lower gastrointestinal tract is predominantly of small-bowel origin. patients presenting with overt blood loss account for a select subpopulation of those with small-bowel bleeding. Although relatively rare, these patients often require repeated blood transfusions, investigation, and hospitalization before a diagnosis is reached. These events have a considerable negative impact on the patient's quality of life. Standard evaluation using enteroclysis, tagged red cell studies, and angiography are proven to be of limited value in this context. Push enteroscopy has significant advantages in this patient group, with the ability to deliver endoscopic therapy. Sonde enteroscopy is now reserved for a few patients to guide decisions on surgery, particularly in those with significant medical comorbidity. Definitive evaluation may require perioperative enteroscopy, but many patients can be managed without the need for surgery. A team approach by physician, radiologist, and surgeon following locally agreed algorithms is essential for the successful management of this challenging clinical problem.
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6/208. Posterior approach for cervical intramedullary arteriovenous malformation with diffuse-type nidus. Report of three cases.

    The treatment of spinal intramedullary arteriovenous malformations (AVMs) with a diffuse-type nidus that contains a neural element poses different challenges compared with a glomus-type nidus. The surgical elimination of such lesions involves the risk of spinal cord ischemia that results from coagulation of the feeding artery that, at the same time, supplies cord parenchyma. However, based on evaluation of the risks involved in performing embolization, together with the frequent occurrence of reperfusion, which necessitates frequent reembolization, the authors consider surgery to be a one-stage solution to a disease that otherwise has a very poor prognosis. Magnetic resonance (MR) imaging revealed diffuse-type intramedullary AVMs in the cervical spinal cords of three patients who subsequently underwent surgery via the posterior approach. The AVM was supplied by the anterior spinal artery in one case and by both the anterior and posterior spinal arteries in the other two cases. In all three cases, a posterior median myelotomy was performed up to the vicinity of the anterior median fissure that divided the spinal cord together with the nidus, and the feeding artery was coagulated and severed at its origin from the anterior spinal artery. In the two cases in which the posterior spinal artery fed the AVM, the feeding artery was coagulated on the dorsal surface of the spinal cord. Neurological outcome improved in one patient and deteriorated slightly to mildly in the other two patients. Postoperative angiography demonstrated complete disappearance of the AVM in all cases. Because of the extremely poor prognosis of patients with spinal intramedullary AVMs, this surgical technique for the treatment of diffuse-type AVMs provides acceptable operative outcome. Surgical intervention should be considered when managing a patient with a diffuse-type intramedullary AVM in the cervical spinal cord.
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7/208. Spinal epidural hematoma caused by extradural arteriovenous malformation: a case report and review of the literature.

    About 330 cases of spinal epidural hematoma have been reported in the literature but few cases had pathologically proven extradural arteriovenous malformation. The authors report a case of spinal epidural hematoma caused by extradural arteriovenous malformation. The patient presented with a sudden onset of back pain followed by rapidly progressive neurological deficit. MRI was the procedure of choice for diagnosis of this lesion. Treatment was emergency surgical decompression. prognosis depends on the preoperative neurological deficit, operative interval and localization of the hematoma.
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8/208. Tentorial meningioma encroaching the transverse sinuses and sigmoid sinus junction area associated with dural arteriovenous fistulous malformation: a case report.

    A 62-year-old woman was evaluated for tinnitis and headache. magnetic resonance imaging and angiography revealed the coexistence of a tentorial tumor encroaching the junction of the right transverse-sigmoid sinuses, and dural arteriovenous fistulous malformation (AVFM) of the right transverse sinus. AVFM was not manipulated at all during the surgery. The pathology was fibroblastic meningioma. Postoperatively, the dural AVFM completely disappeared on follow-up angiography. The fistulas were occluded also after surgery, even though there was no manipulation of the AVFM. It is suggested that the right dominant transverse-sigmoid sinuses are partially occluded by tentorial meningioma, developing the dural arteriovenous fistula of the right transverse sinus. An acquired origin of the dural AVFM was suggested in this case.
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9/208. Demonstration of cerebral plasticity by intra-operative neurophysiological monitoring: report of an uncommon case.

    It has been postulated long ago that "eloquent" areas shift their location in patients with arteriovenous malformations (AVM). Obviously the "motor region" in not located in the precentral gyrus in a patient with an AVM in the "motor region". We report on the case of a 15-year old boy with an AVM in the left sensorimotor cortex, in whom intra-operative mapping showed an inexcitability of the precentral gyrus, while stimulation of the cortex anterior to the primary motor cortex elicited motor responses. This indicates that motor function was translocated from the primary to the supplementary motor cortex. Surgery was performed under general anaesthesia. neurophysiological monitoring was performed throughout surgery. The central sulcus was identified by phase reversal of the somatosensory evoked potentials. The motor cortex was mapped by direct high-frequency (500 Hz) monopolar anodal stimulation. In the patient herein reported, stimulation of the "anatomically" defined primary motor cortex induced no motor response, as expected. Motor response was elicited only by stimulation of the cortex anterior to the precentral gyrus. There was no postoperative deterioration of motor function. These observations indicate that the precentral gyrus was functionally "useless". The motor region was relocated into more rostral areas in the supplementary motor cortex. This translocation of function in the presence of an AVM indicates cerebral plasticity.
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10/208. brain abscesses associated with pulmonary arteriovenous malformations.

    We present three patients with brain abscesses who also had pulmonary arteriovenous malformations (AVMs). All patients had hereditary haemorrhagic telangiectasia (Osler's disease). It is probable that the lung AVMs contributed to the development of the brain abscesses by allowing bacteria easier access to the systemic circulation through a right to left pulmonary vascular shunt, bypassing the filtering action of the pulmonary capillaries. In addition, one patient required a period of postoperative ventilation using PEEP, which may have exacerbated the shunt through the lung AVM and led to difficulty in weaning her from the ventilator.
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ranking = 0.2
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