0:00

This was a very interesting case, and frankly,

0:02

I've never seen an arterial venous malformation in the tongue before.

0:06

But Siresh said that this is one of several cases he's seen.

0:11

So this patient had bleeding from the mouth, patient has had prior treatment.

0:16

So on our C t a examination,

0:20

we see this very dense material,

0:22

which clearly is embolization material. Um,

0:26

the only other thing that could look sort of like this would be, you know,

0:29

bullet fragments from a gunshot wound, uh, which we see a lot in Baltimore,

0:33

Maryland, unfortunately. So, um,

0:38

when you have that dense material, you know that they've treated something.

0:42

And basically the two common things that get treated in

0:47

this location are the quote unquote hemangiomas,

0:52

um, and, um,

0:57

arterio venous malformations. So, um,

1:00

how are we going to be able to distinguish whether this is a, um,

1:05

hemangioma that has not involuted and is

1:10

causing the patient some problems? Again, most likely in this location,

1:13

airway narrowing versus a

1:19

arter venous malformation? Uh,

1:21

at our institution we do what's called twist, m r a,

1:27

in which we do a dynamic contrast injection of gadolinium,

1:32

and we look at whether we see early draining veins,

1:37

uh, versus pooling of contrast

1:43

versus enlarged late occurring draining, uh,

1:47

just veins.

1:48

And those help us to distinguish between a true AAV m versus the various types

1:53

of, uh, heman genomes, uh, or venous vascular malformations.

1:57

I'm using the colloquial term hemangioma,

2:00

but these are venous vascular malformations. Um, and you may have,

2:05

you know, uh, infants and with, with cutaneous hemangioma.

2:08

So those are the entities that we're talking about.

2:12

Fortunately on this C T A when we

2:17

looked at the sagittal reconstructions,

2:20

we are able to identify the,

2:23

a branch coming off of the external carotid artery here. Here's our internal,

2:28

here's our external carotid artery leading to this lesion,

2:32

and we are actually also able to see a

2:37

large vessel,

2:38

even larger than that artery coming and starting to fill the

2:43

jugular vein. So this becomes easy. We have a NIUs,

2:48

we have an artery,

2:49

and we have a draining vein coming out of it leading to early venous

2:53

opacification. So how do we know that this is early venous

2:58

Opacification? We look on the axial scan and we see that although we are seeing

3:04

internal and external carat artery on the left side,

3:07

we are not seeing the jugular vein at all.

3:10

Whereas on the right side,

3:13

we are seeing a partial opacification of the jugular vein here

3:19

when we don't see it in the contralateral side. So

3:25

although this is not the same as a dynamic scan or an arteriogram,

3:29

it's giving us the similar information.

3:31

So this is a true a v m of the tongue that has been partially embolized

3:37

and, um, uh, unusual entity. Um, but uh,

3:42

as I said, uh, although I haven't seen it, uh,

3:45

apparently Resh has seen enough of it that you wanted to include it in your, um,

3:49

case selection. So I don't have much to offer, um,

3:53

more about that case. It was, um, relatively easy. Um,

3:58

once you look at the sagal reformats to suggest that this is a two a V N.