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A 26 year old man with Down's syndrome presented with a 9 month history of progressively deteriorating left hemiparesis, seizures, and then persistent coma despite treatment. Magnetic resonance imaging and angiography confirmed the presence of bilateral dural arteriovenous fistulous malformations, the larger being on the right. Positron emission tomography H2 15O studies (transverse slices A and C) showed high blood flows in the transverse and superior sagittal venous sinuses (indicated by arrows) but globally low cerebral blood flow in both hemispheres (mean of 15.2 ml/100 g/min) compatible with the patient's clinical condition. An EEG showed no epileptic activity but did show a right posterior slow wave abnormality attributable to ischaemia, which is recognised with large dural arteriovenous fistulous malformations.1 2
After endovascular glue embolisation of the right arteriovenous fistulous malformation, PET showed improvement in the global cerebral blood flow to a mean of 26 ml/100 g/min (slices B and D—which are equivalent to slices A and C respectively), the EEG abnormality resolved, and the patient went on to recover to his premorbid neurological state.