Wk 2, Case 3 - Review

Patient History
Bleeding from mouth. Patient has had prior treatment.

Findings
Neck:

CT angiography was performed from the skull base to the thoracic inlet. Patient has undergone prior endovascular embolization in the floor of the mouth with imaging evidence of prior coiling.

CT angiography demonstrates multiple dilated vessels characterized by dilatation of various branches of the lingual artery associated with early draining veins consistent with arteriovenous malformation. The arteriovenous malformation is predominately supplied by an enlarged right lingual artery. The left lingual artery appears to be within normal limits. There are multiple enlarged early draining veins that drain into asymmetrically enlarged right facial vein which drains into the right internal jugular vein.

No obvious evidence of enlarged lymph nodes using standard size criteria.

Visualized portion of the lungs are grossly within normal limits. However, dedicated chest CT is necessary for complete diagnostic evaluation.

CT of circle of Willis:

Anterior Circulation: There is normal appearance of the cervical, petrous, cavernous and paraophthalmic segments of the [bilateral] internal carotid arteries. [Posterior communicating arteries are patent bilaterally. [Bilateral] carotid termini appear normal with normal terminal branching. The [bilateral] middle cerebral artery (MCA) bifurcations are normal with normal appearance of the proximal superior and inferior divisions. The sylvian and distal middle cerebral artery branches are normal in appearance with symmetric arborization without evidence of focal stenosis or large vessel cut-off. [The A1 segments of the bilateral anterior cerebral arteries are normal in appearance]. The anterior communicating artery is patent. [The bilateral A2 segment are patent and symmetric]. No definitive evidence of arteriovenous malformation or aneurysm greater than 5mm is identified.

Posterior Circulation: [Vertebral arteries are codominant] with the extradural vertebral arteries contiguous with the intradural segments. The vertebrobasilar junction opacifies normally as does the basilar artery and basilar tip. There is normal terminal branching of basilar artery with bilateral patent posterior cerebral arteries. [Superior cerebellar arteries are patent bilaterally.] No definite evidence of high-grade focal stenosis, arteriovenous malformation, large vessel cut off or aneurysm greater than 5mm.

Conclusions
1. Right floor mouth arteriovenous malformation predominantly supplied by an enlarged right lingual artery associated with early draining veins.