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Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player

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Title:
Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player
Creator:
Ornella, Anthony
Publication Date:
Language:
English

Subjects

Subjects / Keywords:
Arteriovenous malformations ( jstor )
Blood ( jstor )
Blood vessels ( jstor )
Computerized axial tomography ( jstor )
Imaging ( jstor )
Pain ( jstor )
Radiosurgery ( jstor )
Symptomatology ( jstor )
Thalamus ( jstor )
Traumatic ruptures ( jstor )
Cardiovascular system--Surgery
Radiosurgery
Tomography
Genre:
Undergraduate Honors Thesis

Notes

Abstract:
An 18 year-old male football player presented with symptoms of a severe headache, cervical pain, and photosensitivity after completing conditioning drills. Symptoms did not resolve and actually began to worsen after about 1-hour, so the athlete was referred to the emergency room for imaging. The Computed Tomography (CT) Angiogram ultimately revealed an ateriovenous malformation (AVM). Due to the location and size of the AVM stereotactic radiosurgery was performed to scar and shrink the AVM and reduce the chance of hemorrhaging. Although the radiosurgical procedure is less invasive, it may increase the latent period (recovery time for return to activity). ( en )
General Note:
Awarded Bachelor of Science in Athletic Training; Graduated May 8, 2012 magna cum laude. Major: Athletic Training
General Note:
College/School: College of Health and Human Performance
General Note:
Advisor: Dr. Patricia M. Tripp

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University of Florida
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University of Florida
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Copyright Anthony Ornella. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player INTRODUCTION Cerebral Arteriovenous Malformation (AVM) is a rare, idiopathic condition that occurs in 1% of the general population; occurring when arteries in the brain connect directly to nearby veins and lack capillaries between the two.lAbsence of capillaries decreases gas exchange across the vessels and may cause blood pooling within the brain.lPressure or trauma to the blood vessel may cause the AVM to rupture, reducing proper blood flow to the brain tissue.) Although the conhtion is considered congenital, patients may be asymptomatic until much later in life -with 15-20 year old patients experiencing symptoms most often.) A secondary and potential fatal complication of AVM is an associated cerebral aneury~m.~A cerebral aneurysm is a widening or ballooning of a vessel due to weakness of the wall and is potentially avoidable if proper identification and early intervention are successfully carried out. Although rare, the potential complications associated with AVM rupture require that clinicians have knowledge of key features to both discriminate from non-emergency conditions for appropriate and expedient inte~ention.~ The following case summary highlights the diagnostic procedures, surgical management and return to participation recommendations for a collegiate football athlete with an AVM rupture. CASE REVIEW A healthy 18-year old collegiate football athlete, presented to the athletic training staff during spring practice complaining of an intense headache, cervical pain, and photosensitivity. He was removed from practice 10-minutes after the onset of symptoms. The athlete reported no previous hstory of severe headaches or migraines. When describing the initial onset of symptoms, he reported feeling a pop in his head

PAGE 2

followed by immediate pain as he performed single legged bounding exercises. The pain was localized over the posterior portion of his head and neck. Vital sign measures yielded slightly elevated oral temperature (99.8F) and normal blood pressure (recorded form the antebrachial fossa) using an automated reader (116/72). He was alert and oriented but uncharacteristically scared and nervous. Range of motion (ROM) (active, passive and resistive) was assessed to identify the root of reported cervical pain yielding normal results. The atraumatic nature of the injury, no reported concussion-like symptoms and normal cranial nerve function discounted traumatic brain injury. During functional movements (similar to the dynamic warm-up) and any bounding activity, the athlete reported increased pain deep in the right occipital region. Meningitis and encephalitis testing (Kernig's and Brudzinski's tests) yielded negative results and the initial suspicion was a migraine headache. The athlete returned to the athletic training facility approximately 1-hr post-practice with intensified symptoms and was transported to the emergency room for further evaluation. Computed Tomography (CT) imaging revealed an acute intraparenchymal hemorrhaging near the right thalamus, with intraventricular extension in the right lateral, left lateral, third, and fourth ventricles. After additional imaging, a CT angiogram showed a 1.8 cm AVM of the right thalamus, with no cerebral aneurysm. After two days of bed rest in the hospital, Magnetic Resonance Imaging (MRI) suggested reabsorption of the intraventricular blood and the athlete was discharged. He remained under 24-hour supervision (with family) to ensure safe recovery. Initial Management and Surgical Intervention After two weeks of complete rest and pain medication the athlete was seen by a neurosurgeon to discuss management options. After discussing various treatment methods, the patient opted for a surgical intervention over a pharmacological

PAGE 3

treatment option; non-surgical management would increase the likelihood the patient would suffer from another cranial bleed if he returned to sport participation. Surgical intervention would allow for the athlete's return to sport after the latency period (e.g., 1-2 years) with a reduced chance of relapse. Due to the size and location of his AVM, a Stereotactic Radiosurgery procedure has the highest rate of success. Stereotactic Radiosurgery uses focused radiation to scar, shrink, and obliterate the AVM.'During the closed surgical procedure, the patient's head was fixed in a halo brace and 20-25 Gy (units of measure for the radiation) bursts of energy were delivered (entire procedure lasted 43 minutes). After post-operative imaging suggested successful shrinking of the AVM occurred, no additional radiation treatments were necessary. The patient was prescribed Warfarin to reduce risk of clotting or aneurysm. Six months following the radiosurgical procedure the athlete was asymptomatic and began bodyweight resistance training and discontinued use of Warfarin. During the succeeding month, the athlete incorporated isotonic strength training, plyometric and sports specific drills (e.g., cutting, speed training, bounding, etc.) progressing as tolerated. After 12 months, the athlete was cleared for participation in football activities. He is required to have annual follow-up imaging to monitor the healing of the AVM, but no sport restrictions are imposed unless symptoms return. DISCUSSION A cerebral AVM is a rare congenital idiopathic condition. Hemorrhage from a rupture may present with symptoms such as seizures, headaches, migraines, or in some cases sudden death.' Symptoms can be acute or gradual, depending on the size and location of the bleeding.2 In this case, a severe headache resulted from a bounding activity (likely because of increased diastolic blood pressure); however dynamic movements are not required to elicit symptoms.'

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Patients with an AVM may present with symptoms such as a headache or photophobia (i.e., mimicking a concussion), but occurring from non-traumatic origins. Most cases yield unremarkable changes to cranial nerve function and cervical spine muscle function, but photosensitivity maybe present.' Balance could be impaired in advanced stages and functional (dynamic) movements may increase ~ymptoms.~ Proper clinical assessment should rule out other conditions (e.g., migraine headache, concussion) and consider referral for imaging to rule-out AVM when other diagnoses are excluded. Currently no clinical test isolates the presence of an AVM.' Sagittal and transverse CT scans are most commonly used to identify the accumulation of blood, but a CT angiogram is the gold standard in identifying the presence of the AVM.' No research suggests AVM's discriminate to specific race, gender, or sport, but family hlstory may predispose an individual to having the condition.' Proper preseason screening (through medical history) would be valuable to aid with identification. Stereotactic radiosurgery is utilized frequently to treat AVM's smaller than 4 cm in diameter, which are located in the eloquent part (e.g., area for communication, perception) of the brain. However, this radiosurgical procedure has been shown to be ineffective in treating medium or large AVM's? A typically dosage of 20-25 Gy has a morbidity rate of 2%-4% and a mortality rate of 0%-I%.' Although 50% of patients heal within a year, for 85% of patients hew may take up to two years.'If a patient shows signs of an unsuccessful surgery symptoms of a intracranial bleed or contralateral coordination or muscle weakness may occur within the latency period? Athletes presenting with symptoms of AVM, should be removed from activity until the determined course of treatment is initiated, whether it be bed rest, medication or stereotactic radiosurgery. Stereotactic radiosurgery is more successful with AVM's s4 cubic cm2; however, alternative options for treatment may include

PAGE 5

resection (craniotomy), cerebral embolization or the combination of the two, which may provide better outcomes for AVM of increased size or a different 10cation."~ Sport participation may be restricted if symptoms persist or complications arise; typical return to play protocols include resistance training, functional exertion activities and normal CT imaging. CONCLUSION Unprovoked migraine headache and/or seizure-like symptoms should warrant referral for imaging (e.g., CT angiogram) to identity fluid accumulation or vascular abnormality to accurately diagnosis an AVM. Surgical options can yield success for the smaller AVM and may afford the athlete an opportunity to return to competitive sporL3 Return to participation is dependent upon treatment type and results of follow-up imaging to rule out complications secondary to the initial AVM.

PAGE 6

115 References 1. Yilmaz A, Musluman A, Kanat A, Cavusoglu H, Terzi Y, Aydin Y. The correlation between hematoma volume and outcome in ruptured posterior fossa arteriovenous malformations indicates the importance of surgical evacuation of hematomas. Turk Neurosurg. 2011; 21(2):152-9. 2. Ahn S, Choo I, Kim J, Kim H. Arteriovenous malformation with an occlusive feeding artery coexisting with unilateral moyamoya disease. J Clin Neurol. 2010 Dec;6(4):216-20. 3. Xu H, Qin Z, Gu Y, Zhou P, Chen X. Diagnostic value of contrast-enhanced intraoperative doppler sonography for cerebral arteriovenous malformations compared with angiography. Chin Med J. 2010;123(20):2812-2815 4. Deruty R, Pelissou-Guyotat I, Morel C, Bascoulergue Y, Turjman F. Reflections on the management of cerebral arteriovenous malformations. Surg Neurol. 1998; 50:245-56.

PAGE 7

Figure Legend Figure 1: Sagittal MRI view, showing blood accumulation due to the weakened vessels around the Thalamus. Figure 2: Transverse MRI view revealing the AVM in the right Thalamus.

PAGE 8

Figure 1: Sagittal MRI view, showing blood accumulation due to the weakened vessels around the Thalamus. Figure 2: Transverse MRI view revealing the AVM in the right Thalamus.



PAGE 1

Honors Thesis Submission Form Major: Designation: Graduation Term: Name Anthony Ornella UF ID 6803-6106 Thesis Title Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player Date 04/24/2012 Length 8 pages Bibliography Yes No Illustrated Yes No College Health and Human Performance Thesis Advisor Dr. Patricia Tripp Advisor's Department Applied Physiology and Kinesiology Is your thesis or any part being submitted for publication? Yes No If any part has been submitted for publication, please indicate where: International Journal of Athletic Therapy & Training Keywords (provide five key words) arteriovenous malformation, stereotactic, radiosurgery, cerebral hemorrhage, thalamus Abstract (100-200 Words) hn 18 ywr-old male footlnll phgcr prcwntcd uich s).mpmrnr
PAGE 2

Magna Cum Laude Thesis Paper College of Health and Human Performance Department of Applied Physiology and Kinesiology Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player Anthony J. Ornella I UF ID: 6803-6106 Department ~hairbdlichael Delp Manuscript prepared in the International/ournal ofAthletic Therapy and Training format for submission in May 2012

PAGE 3

ABSTRACT An 18 year-old male football player presented with symptoms of a severe headache, cervical pain, and photosensitivity after completing conditioning drills. Symptoms did not resolve and actually began to worsen after about 1-hour, so the athlete was referred to the emergency room for imaging. The Computed Tomography (CT) Angiogram ultimately revealed an arteriovenous malformation (AVM). Due to the location and size of the AVM stereotactic radiosurgery was performed to scar and shrink the AVM and reduce the chance of hemorrhaging. Although the radiosurgical procedure is less invasive, it may increase the latent period (recovery time for return to activity).

PAGE 4

Non-Contact Presentation of Arteriovenous Malformation in the Right Thalamus of a Collegiate Football Player INTRODUCTION Cerebral Arteriovenous Malformation (AVM) is a rare, idiopathic condition that occurs in 1% of the general population; occurring when arteries in the brain connect directly to nearby veins and lack capillaries between the two.lAbsence of capillaries decreases gas exchange across the vessels and may cause blood pooling within the brain.lPressure or trauma to the blood vessel may cause the AVM to rupture, reducing proper blood flow to the brain tissue.) Although the conhtion is considered congenital, patients may be asymptomatic until much later in life -with 15-20 year old patients experiencing symptoms most often.) A secondary and potential fatal complication of AVM is an associated cerebral aneury~m.~A cerebral aneurysm is a widening or ballooning of a vessel due to weakness of the wall and is potentially avoidable if proper identification and early intervention are successfully carried out. Although rare, the potential complications associated with AVM rupture require that clinicians have knowledge of key features to both discriminate from non-emergency conditions for appropriate and expedient inte~ention.~ The following case summary highlights the diagnostic procedures, surgical management and return to participation recommendations for a collegiate football athlete with an AVM rupture. CASE REVIEW A healthy 18-year old collegiate football athlete, presented to the athletic training staff during spring practice complaining of an intense headache, cervical pain, and photosensitivity. He was removed from practice 10-minutes after the onset of symptoms. The athlete reported no previous hstory of severe headaches or migraines. When describing the initial onset of symptoms, he reported feeling a pop in his head

PAGE 5

followed by immediate pain as he performed single legged bounding exercises. The pain was localized over the posterior portion of his head and neck. Vital sign measures yielded slightly elevated oral temperature (99.8F) and normal blood pressure (recorded form the antebrachial fossa) using an automated reader (116/72). He was alert and oriented but uncharacteristically scared and nervous. Range of motion (ROM) (active, passive and resistive) was assessed to identify the root of reported cervical pain yielding normal results. The atraumatic nature of the injury, no reported concussion-like symptoms and normal cranial nerve function discounted traumatic brain injury. During functional movements (similar to the dynamic warm-up) and any bounding activity, the athlete reported increased pain deep in the right occipital region. Meningitis and encephalitis testing (Kernig's and Brudzinski's tests) yielded negative results and the initial suspicion was a migraine headache. The athlete returned to the athletic training facility approximately 1-hr post-practice with intensified symptoms and was transported to the emergency room for further evaluation. Computed Tomography (CT) imaging revealed an acute intraparenchymal hemorrhaging near the right thalamus, with intraventricular extension in the right lateral, left lateral, third, and fourth ventricles. After additional imaging, a CT angiogram showed a 1.8 cm AVM of the right thalamus, with no cerebral aneurysm. After two days of bed rest in the hospital, Magnetic Resonance Imaging (MRI) suggested reabsorption of the intraventricular blood and the athlete was discharged. He remained under 24-hour supervision (with family) to ensure safe recovery. Initial Management and Surgical Intervention After two weeks of complete rest and pain medication the athlete was seen by a neurosurgeon to discuss management options. After discussing various treatment methods, the patient opted for a surgical intervention over a pharmacological

PAGE 6

treatment option; non-surgical management would increase the likelihood the patient would suffer from another cranial bleed if he returned to sport participation. Surgical intervention would allow for the athlete's return to sport after the latency period (e.g., 1-2 years) with a reduced chance of relapse. Due to the size and location of his AVM, a Stereotactic Radiosurgery procedure has the highest rate of success. Stereotactic Radiosurgery uses focused radiation to scar, shrink, and obliterate the AVM.'During the closed surgical procedure, the patient's head was fixed in a halo brace and 20-25 Gy (units of measure for the radiation) bursts of energy were delivered (entire procedure lasted 43 minutes). After post-operative imaging suggested successful shrinking of the AVM occurred, no additional radiation treatments were necessary. The patient was prescribed Warfarin to reduce risk of clotting or aneurysm. Six months following the radiosurgical procedure the athlete was asymptomatic and began bodyweight resistance training and discontinued use of Warfarin. During the succeeding month, the athlete incorporated isotonic strength training, plyometric and sports specific drills (e.g., cutting, speed training, bounding, etc.) progressing as tolerated. After 12 months, the athlete was cleared for participation in football activities. He is required to have annual follow-up imaging to monitor the healing of the AVM, but no sport restrictions are imposed unless symptoms return. DISCUSSION A cerebral AVM is a rare congenital idiopathic condition. Hemorrhage from a rupture may present with symptoms such as seizures, headaches, migraines, or in some cases sudden death.' Symptoms can be acute or gradual, depending on the size and location of the bleeding.2 In this case, a severe headache resulted from a bounding activity (likely because of increased diastolic blood pressure); however dynamic movements are not required to elicit symptoms.'

PAGE 7

Patients with an AVM may present with symptoms such as a headache or photophobia (i.e., mimicking a concussion), but occurring from non-traumatic origins. Most cases yield unremarkable changes to cranial nerve function and cervical spine muscle function, but photosensitivity maybe present.' Balance could be impaired in advanced stages and functional (dynamic) movements may increase ~ymptoms.~ Proper clinical assessment should rule out other conditions (e.g., migraine headache, concussion) and consider referral for imaging to rule-out AVM when other diagnoses are excluded. Currently no clinical test isolates the presence of an AVM.' Sagittal and transverse CT scans are most commonly used to identify the accumulation of blood, but a CT angiogram is the gold standard in identifying the presence of the AVM.' No research suggests AVM's discriminate to specific race, gender, or sport, but family hlstory may predispose an individual to having the condition.' Proper preseason screening (through medical history) would be valuable to aid with identification. Stereotactic radiosurgery is utilized frequently to treat AVM's smaller than 4 cm in diameter, which are located in the eloquent part (e.g., area for communication, perception) of the brain. However, this radiosurgical procedure has been shown to be ineffective in treating medium or large AVM's? A typically dosage of 20-25 Gy has a morbidity rate of 2%-4% and a mortality rate of 0%-I%.' Although 50% of patients heal within a year, for 85% of patients hew may take up to two years.'If a patient shows signs of an unsuccessful surgery symptoms of a intracranial bleed or contralateral coordination or muscle weakness may occur within the latency period? Athletes presenting with symptoms of AVM, should be removed from activity until the determined course of treatment is initiated, whether it be bed rest, medication or stereotactic radiosurgery. Stereotactic radiosurgery is more successful with AVM's s4 cubic cm2; however, alternative options for treatment may include

PAGE 8

resection (craniotomy), cerebral embolization or the combination of the two, which may provide better outcomes for AVM of increased size or a different 10cation."~ Sport participation may be restricted if symptoms persist or complications arise; typical return to play protocols include resistance training, functional exertion activities and normal CT imaging. CONCLUSION Unprovoked migraine headache and/or seizure-like symptoms should warrant referral for imaging (e.g., CT angiogram) to identity fluid accumulation or vascular abnormality to accurately diagnosis an AVM. Surgical options can yield success for the smaller AVM and may afford the athlete an opportunity to return to competitive sporL3 Return to participation is dependent upon treatment type and results of follow-up imaging to rule out complications secondary to the initial AVM.

PAGE 9

115 References 1. Yilmaz A, Musluman A, Kanat A, Cavusoglu H, Terzi Y, Aydin Y. The correlation between hematoma volume and outcome in ruptured posterior fossa arteriovenous malformations indicates the importance of surgical evacuation of hematomas. Turk Neurosurg. 2011; 21(2):152-9. 2. Ahn S, Choo I, Kim J, Kim H. Arteriovenous malformation with an occlusive feeding artery coexisting with unilateral moyamoya disease. J Clin Neurol. 2010 Dec;6(4):216-20. 3. Xu H, Qin Z, Gu Y, Zhou P, Chen X. Diagnostic value of contrast-enhanced intraoperative doppler sonography for cerebral arteriovenous malformations compared with angiography. Chin Med J. 2010;123(20):2812-2815 4. Deruty R, Pelissou-Guyotat I, Morel C, Bascoulergue Y, Turjman F. Reflections on the management of cerebral arteriovenous malformations. Surg Neurol. 1998; 50:245-56.

PAGE 10

Figure Legend Figure 1: Sagittal MRI view, showing blood accumulation due to the weakened vessels around the Thalamus. Figure 2: Transverse MRI view revealing the AVM in the right Thalamus.

PAGE 11

Figure 1: Sagittal MRI view, showing blood accumulation due to the weakened vessels around the Thalamus. Figure 2: Transverse MRI view revealing the AVM in the right Thalamus.