Cerebral vascular malformations: Viva

Branch 1: Classification and the bedside recognition

The candidate should classify cerebral vascular malformations into the high-flow arteriovenous malformation, the vein of Galen aneurysmal malformation, the low-flow cavernous malformation, and the developmental venous anomaly. A strong candidate states that the high-flow lesions present with haemorrhage or cardiac failure, that the low-flow lesions present with seizures, and that the developmental venous anomaly is found incidentally and left alone. The candidate should then state that this neonate, with the high-output cardiac failure and the loud cranial bruit, has the classic presentation of a vein of Galen malformation, because the malformation is the commonest extracardiac cause of high-output cardiac failure in the newborn. ^[4][1]

If the examiner presses on the bedside recognition, the candidate should state that the loud cranial bruit over the vertex is the clue that the heart failure is driven by an intracranial shunt and not by an intrinsic cardiac lesion. The echocardiogram shows a structurally normal heart, and the high-output state points to the extracardiac shunt. The candidate should request the urgent cranial ultrasound or the MRI brain with MRV to confirm the enlarged midline venous sac and the feeding choroidal arteries, and should arrange the early retrieval to a paediatric interventional neuroradiology centre. ^[5][3]