A case of severe multiple injuries due to a traffic accident with an intracerebral hemorrhage possibly caused by the rupture of an angiographically occult arteriovenous malformation

Abstract

An angiographically occult arteriovenous malformations (AOAVM) are cerebrovascular malformations that are not demonstrable on cerebral angiography. This report presents a case of a putaminal hemorrhage associated with severe multiple injuries caused by a traffic accident. A 24-year-old female was transferred to the nearest emergency hospital by ambulance. She was thereafter transferred to our department because of multiple high-energy injuries. A brain CT scan showed the existence of a putaminal hemorrhage without a cerebral contusion. The injury severity score was 48 on admission. Transcatheter arterial embolization was performed for the left renal injury. The traction of the right femoral bone with Kirschner wire was performed. In addition, disseminated intravascular coagulation was treated with massive blood transfusions including the fresh frozen plasma. A follow-up CT scan revealed a mild regrowth hematoma three hours after admission. Therefore, the patient further underwent emergency cerebral angiography which suggested an arteriovenous malformation. However, no vessel abnormalities were found. A cerebral herniation was demonstrated by CT scan six hours after admission. An emergency operation was therefore immediately performed. A hard mass was found in the hemorrhage during surgery. An AOAVM was thus revealed in the pathological examination. Regarding the differential diagnosis of an intracerebral hemorrhage in a young age patient or a patient without hypertension, this was considered to be an AOAVM.