This document describes the case of a 40-year-old male who presented with headache, seizures, and altered consciousness. His history included a focal cortical lesion diagnosed in 2013 for which he had been on antiepileptics. Examination found left inferior quadrantanopia and weakness in the left upper extremity. Imaging revealed a right parietal arteriovenous malformation (AVM), which was surgically excised via a posterior parietal craniotomy. Post-operatively, power in the left upper extremity improved with no new deficits. Complications of the procedure and long-term outcome were discussed.

1. DR.MUMTAZ ALI
DEPARTMENT OF NEUROSURGERY
JPMC KARACHI

2. HISTORY
 40 years old, right handed, married, Muslim male, waiter by
profession, resident of Karachi with NKCM admitted via
emergency with c/o:
 Headache 3 hours
 Fits for 3 hours
 Altered level of consciousness for 2 hours
 Vomiting 3-4 episodes

3.  According to patient’s wife, the patient was in his usual
state of health when he developed sudden headache at 3:00
am following which he had one episode of seizure which
lasted for 5-6 minutes, tonic-clonic associated with
frothing and urinary incontinence.Postictal numbness of
left arm followed by altered level of consciousness and
three episodes of vomiting.
 The patient had been diagnosed with the focal cortical
lesion in 2013, for which he was initially managed
conservatively with antiepileptics. His frequency of
seizures increased gradually therefore he was advised
surgical intervention for which they had refused.
 She denies constitutional symptoms like fever, night
sweats, weight loss.

4.  Lobar symptoms : unremarkable
 Cranial nerve symptoms : unremarkable
 Cerebellar symptoms :unremarkable
 Endocrine symptoms : unremarkable
 Systemic symptoms : unremarkable
 Past medical and surgical hx : Not significant
 Personal hx : not significant
 Drug hx : On Carbamazepine for past 2 years.
 Allergy: Not significant
 Family Hx: Not significant

5. Level and D/D
 LEVEL : Right parietal region
 D/D :
 AVM
 Tumor bleed
 cavernoma

6. EXAMINATION
 Middle aged male lying uncomfortably on the bed.
 Vitals:
 BP: 130/80mmHg - RR: 16/min
 HR: 96/min - Temp: AF
 Non vitals : not present
 GCS: 15/15
 Pupils: BERL
 Higher mental functions: Intact
 Cranial nerves: left inferior quadrantanopia
 Rest of the cranial nerves intact.
 No Cerebellar signs

7.  Sensory system: Grossly intact
 Motor system:
Upper limb Lower limb
R L R L
Bulk N N N N
Tone N N N N
Power 5/5 4/5 5/5 5/5
Reflexes 2+ + 2+ 2+
Plantars ↓ upgoing
Clonus Knee & Ankle - ve

8. Level and D/D
 LEVEL : Right parietal region
 D/D :
 AVM
 Tumor bleed
 cavernoma

9. Investigations
 Specific :
 CT scan brain
 CT angiogram
 MRI brain with contrast
 Routine :
 CBC , SUCE , PT/APTT/INR , Hep b and c , CXR
 Relevant :

15. Diagnosis and management
 Right parietal AVM
 Management :
 Counselling after admission
 Optimization
 Preop care : propranolol and labetalol
 Surgery : Posterior parietal craniotomy and excision
 Postop care
 Followup
 Rehabilitation
 outcome

16. Posterior parietal craniotomy
 Shifting:
 Position : supine & head is turned on left side
 Equipment : Microscope , bipolar , dopppler
u/s , neuromonitoring
 Incision : Horse shoe
 Craniotomy : Posterior Parietal
 Durotomy : c-shaped based on sss
 Microscopic dissection :
 Arachnoid plane is identified
 Feeding arteries , nidus ,Draining vein
identified
 4 major Feeders identified and clipped
 Nidus excised
 Draining vein clipped
 Hemostasis secured
 Dural repair
 Wound closure

17. POST OPERATIVE COURSE
 Power in left upper extremity improved
 No further deficit
 Repeat CT angiogram brain after 2 weeks

20. Complications and outcome
 Normal pressure break through
 Occlusive hyperemia
 Cerebral edema
 Rebleed from retained nidus
 Seizure
 Hematoma
 Neurological deficit
 Craniotomy complication

21. Thankyou