NEUROVASCULAR BRIEF OPERATIVE NOTE:
"Date of Procedure: 4/16/2019 Preoperative Diagnosis: DVA cerebellar and deep venous system, dilatation LA2 Postoperative Diagnosis: DVA cerebellar and deep venous system, aneurysm LA2 Procedure: cerebral angiography Anesthesia: ivms, local Estimated Blood Loss: minimal Findings: Duplicated ACoA Aneurysm LA2 mid segment 2.8mm x 2.1mm x 1.6mm with neck 1.8mm x 1.5mm Cervicocerebral arterial dolichoectasia No cervicocerebral arteriovenous shunt Cerebral venous dolichoectasia DVA superior cerebellar vein from left more than right cerebellar hemispheres DVA VoG and deep venous system Complications: none immediate" Time to see the Cardiologist. (White outline below shows the aneurysm)
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MRI results were not conclusive, so a CT angiogram was ordered and it was confirmed, I have a brain aneurysm.
Impression: 1. Prominent number and caliber of venous structures in the left side. Most apparent in the region of aneurysmal vein of Galen and left ambient cistern. -The findings are more characteristic of large caliber/complex developmental venous anomaly. -No CTA or MR confirmation of AV shunting. No arteriovenous tangle of vasculature. -Consider subsequent evaluation with catheter angiography for further characterization 2. Vascular lesion of intraconal left orbit. Suggests some form of hemangioma. Indeterminate as to whether not related to the above-described venous finding. 3. There is a 2 mm aneurysmal outpouching of the A2 segment of left ACA as described above. 4. Looping right AICA into the right IAC; any right-sided pulsatile tinnitus symptoms? Thank you for enabling us to participate in the care of this patient. NarrativeEXAM: CTA HEAD NECK W CONT CLINICAL INDICATIONS: Pulsatile tinnitus, unspecified; affecting left ear; sudden sensorineural hearing loss; patient underwent prior MRI, which demonstrated prominent venous structures in the region of left ambient cistern, with high flowrate, raising possibility of an AV fistula. TECHNIQUE: Helical CT scan of the brain and neck were performed at 1.25 mm intervals during rapid IV bolus contrast administration. These data were reconstructed at .625 mm intervals for vascular analysis. The data was also reviewed at 2.5 mm intervals for accompanying soft tissue analysis. 3D post processed images, including surface shaded displays, were produced for this exam on independent console, permanently archived and interpreted. All CT scans at this facility are performed using dose optimization technique as appropriate to a performed exam, to include automated exposure control, adjustment of the MA and/or kV according to patient size (including appropriate matching for site-specific examinations) or use of iterative reconstruction technique. CONTRAST: 100 cc Isovue 370 COMPARISON: MRI 1/31/2019 CTA SOFT TISSUE ANALYSIS: Lungs: Clear Upper chest: Unremarkable Neck: Unremarkable Lymph nodes: No adenopathy Orbits: Similar to MRI, a plethora of serpentine vascular structures in the left retro-orbital region, primarily intraconal. Most of these do not enhance during the arterial phase of evaluation. They do visibly enhance on the MRI. There is some mass effect on the left optic nerve, as this focus is predominantly along its medial aspect. No proptosis. Right orbit unremarkable. Paranasal sinuses: Clear Brain: No hemorrhage or mass effect. Bones: Unremarkable for age. CTA NECK VASCULAR ANALYSIS: Aortic arch: Left sided with typical configuration. Innominate: Patent Right Subclavian: Patent Left Subclavian: Patent Right carotid: -CCA: Patent -ECA: Patent -ICA: Patent. Estimated <10% atherosclerotic stenosis of proximal ICA by NASCET criteria. Left carotid: -CCA: Patent. -ECA: Patent. -ICA: Patent. Ectatic caliber of its distal skull base aspect. Estimated <10% atherosclerotic stenosis of proximal ICA by NASCET criteria. Right vertebral: Patent Left vertebral: Patent CTA BRAIN VASCULAR ANALYSIS: Right anterior circulation: -ICA: Patent -ACA: Patent -MCA: Patent Left anterior circulation: -ICA: Patent -ACA: Hypoplastic A1 segment, patent downstream. Arising from the proximal aspect of the A2 segment, there is a 2 mm aneurysmal outpouching directed left posteriorly as on axial series 4 images 456-461. -MCA: Patent -ACOM: Unremarkable -PCOM: Not evident Posterior circulation: -RVA: Patent -LVA: Patent -Basilar: Vessel itself is patent. -The right AICA does look into the deep aspect of the right internal auditory canal. -A left AICA is not clearly evident, nor is there vessel looping into the left IAC. -Right PCA: Patent -Left PCA: Patent, slightly larger caliber compared with right side but not uniformly so. Major venous structures: As noted, plethora of venous structures within the left ambient cistern region. -Large communication to the bulbous vein of Galen. - More sizable venous structures within the left side of 4th ventricle extending into the central cerebellar parenchyma - Sizable branches extending anteriorly along the ambient cistern - Slight asymmetric prominence in the number of small caliber venous structures in the region of left cavernous sinus, potentially communicating to the aforementioned left orbital vascular plethora -Slight asymmetric prominent caliber of left cerebral cortical surface venous structures - Superior sagittal sinus is unremarkable; prominent caliber of cortical surface remains along left vertex - Straight sinus itself is relatively narrow when viewed axially - Dominant left transverse and sigmoid sinus drainage system; they are patent - Right-sided dural venous sinus structures and right internal jugular vein are patent - No gross tangle/nidus of vasculature Now to see a neurologist to see what can be done, if anything. Let the adventure begin. MRI result are in: "There is an
incidental small fluid collection in the anterior middle cranial fossa consistent with an incidental benign arachnoid cyst. There is an additional probable arachnoid cyst superior and slightly dorsal to the cerebellar vermis. Follow CSF on all sequences. Measures up to 1.1 cm transverse, 2.5 cm AP and 1.3 cm SI (sagittal T1 precontrast series 4 image 12). No hydrocephalus. Vascular System: Grossly patent flow in basilar and internal cerebral arteries. No findings of dural sinus thrombosis. Small enhancing vascular structure in the medial aspect of the left cerebellum is consistent with a developmental venous anomaly. The DVA has a prominent draining vein that extends into the left ambient cistern (axial T2 images 12-13). This DVA appears to drain to the prominent venous structure in the left supravermian space and extends dorsal to the torcula. Unclear if this prominent venous structure represents the straight sinus and is displaced by the fluid space above the vermis suspicious for arachnoid cyst described above. This prominent venous structure indicates with left transverse dural sinus, which is also prominent (axial T2 images 9-12) and appears to have high flowrate based on the pulsation artifact seen on axial T1 postcontrast series 13 images 8-12. The right transverse dural sinus is smaller caliber but patent. 1 cm T2 hyperintense signal focus along the margin of the superior sagittal sinus anteriorly appears to be a small arachnoid granulation (axial T1 postcontrast image 25). Cerebellum: No acute abnormality. Again, small developmental venous anomaly in the medial left cerebellum. No associated cavernous malformation. The cerebellar tonsils extend to the level of the foramen magnum but no Chiari I malformation." Doctor visit on 2/14 to see what all this means, but it doesn't look good so far. Hearing loss continues, times to see a specialist. Specialist orders MRI and prescribes steroids. Steroids did nothing for the hearing loss.
Second week of December, sudden hearing loss and a slight loss of balance.
Had a wonderful day and was very thankful for being able to spend time with family today.
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