22 year old working at an I.T Firm experienced severe headache and fell unconscious on a normal working day at her workplace.
She was then admitted to a nearby hospital in the same unconscious state. After a primary diagnosis she was shifted to Well Known hospital for further management.
A CT Scan was done upon admission which showed bleeding in the Left Parietal Region. an emergency cerebral angiography was done to detect the cause of the sudden bleed in an apparently normal young girl.
The reports showed that she had an intracranial AVM (arteriovenous malformation) which had ruptured and bled. An arteriovenous malformation is an abnormal communication between the arteries and the veins which are prone to rupturing and bleeding. Any bleeding inside the brain is complex but the AVM made it much more complex. The surgical procedure in such cases becomes extremely challenging. the other major challenge that doctors had to face in this case was that the bleeding was in the Left Parietal Region which meant that the patients speech, comprehension and movement of the right side of the body was likely to be severely affected by procedure in that area. There was no room for even the minutest error.
It should be noted that Any AVM at such vital sites of the brain diagnosed prior to the bleeding is a therapeutic dilemma as its removal can cause severe neurological deficits involving speech and paralysis. Hence surgeons rarely excise the AVM at such eloquent sites and are forced to treat them using less effective modalities.
Having left with no choice but to operate because of the large life threatening bleed, Neurosurgeon “Dr. Sunil Kutty – Minimal Access Brain & Spine Surgeon” decided to evacuate the clot and excise the AVM along it. If successful the surgical procedure would save the patient’s life and also cure her from the AVM. After opening the skull. The large bleed was initially evacuated without touching the AVM which could rupture even during the surgery by the slightest provocation. Then we turned our attention to the AVM excision. The periphery of the AVM was delineated and gradually its blood supply cut off one by one without causing further injury to the brain already damaged by the bleed. After achieving complete microscopic excision of the AVM and clot evacuation also the brain was swollen and angry looking, hence the bone flap was not kept back to allow the brain to swell out and relieve the pressure within the skull.
The operation was a success and the patient made a gradual recovery. After a couple of weeks in the ICU and once she had retained her consciousness, to our relief , we found that she had no neurological deficit i.e. her speech and comprehension and movement of the right side of the body were normal. Once the brain swelling had settled the bone flap was also put back by a surgical procedure called Cranioplasty. She was soon discharged and even joined back her work. but she still had one more hurdle to clear, she had to undergo angiography to confirm the completeness of the AVM excision, Which she did a few weeks later. The angiography read -Normal cerebral angiography, which meant she was cured.
According to “Dr. Sunil Kutty – Minimal Access Brain & Spine Surgeon” If not for the bleed the AVM at such eloquent sites, are extremely difficult to treat because the decision making involves cure on one side and severe neurological deficits on the other, in an absolutely normal looking patient.
So, To think of it, it was the catastrophic bleed which forced us to intervene in emergency in the most radical manner and achieve cure without any Neuro deficit in this young girl. Indeed a blessing in disguise!”