How do I get a provider to see an 18-year-old male patient with a history of seizures due to a deep Arteriovenous Malformation (AVM) as soon as possible?

Urgent Neurosurgical Evaluation for AVM with Seizures

This 18-year-old male with a deep AVM and seizures requires urgent (not emergent) neurosurgical consultation, ideally within 1-2 weeks, to assess treatment options and seizure management, as AVM-associated seizures significantly impact quality of life and may indicate need for definitive intervention.

Immediate Steps to Expedite Provider Evaluation

Contact Neurosurgery Directly

• Call the neurosurgery service directly rather than relying on routine referral processes, emphasizing the patient's age and seizure burden 1
• Highlight that this is an 18-year-old with lifetime hemorrhage risk of approximately 87% (calculated as 105 - 18 years = 87%) 1, 2
• Emphasize the 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage 1, 2

Key Information to Communicate

• Seizure characteristics: frequency, type (focal vs. generalized), medication response, and impact on daily function 1, 3
• Deep AVM location: this is critical as deep AVMs carry higher surgical risk but also higher hemorrhage risk 1
• Prior hemorrhage history: if present, this increases first-year re-hemorrhage risk to 6-32.9% 1, 2
• Current imaging: ensure MRI and cerebral angiography are available or scheduled, as both are required for comprehensive evaluation 1, 4, 2

Clinical Urgency Rationale

Why This Patient Needs Prompt Evaluation

Seizure Control and Quality of Life

• 20-25% of AVMs present with seizures, and uncontrolled epilepsy considerably reduces quality of life 1, 5, 3
• Seizure control is an important surgical goal that can be achieved in 80-96% of patients after AVM resection 1, 6
• Early surgery in young patients with epilepsy is an important consideration to prevent secondary epileptogenesis 7

Age-Related Hemorrhage Risk

• Young age confers a high lifetime hemorrhage risk due to decades of exposure 1, 2
• Pediatric and young adult patients have 25% mortality from hemorrhagic events 1
• The annual 2-3% hemorrhage risk compounds over this patient's expected lifespan 1, 2

Deep AVM Considerations

• Deep location is associated with higher hemorrhage risk 1, 2
• Deep AVMs require specialized multidisciplinary evaluation for treatment planning 1
• These lesions may require combined therapy (embolization plus surgery or radiosurgery) 1

Timing Framework

Not Emergent Unless:

• Active hemorrhage with mass effect requiring urgent hematoma evacuation 1
• Status epilepticus or rapidly escalating seizure frequency
• New focal neurological deficits suggesting recent hemorrhage

Urgent (1-2 Weeks) Because:

• AVM resection is typically elective but should not be unnecessarily delayed in young patients with seizures 1
• Comprehensive evaluation requires time for proper imaging (MRI and 4-vessel angiogram) and multidisciplinary planning 1, 4
• Seizure burden impacts quality of life and warrants timely intervention 3, 6

Practical Approach to Expedite Consultation

Documentation Strategy

When contacting neurosurgery, structure your communication:

1. Patient age and seizure presentation (emphasizes lifetime risk and quality of life impact)
2. Deep AVM location (indicates complexity requiring specialized evaluation)
3. Current seizure control status (medication-refractory seizures warrant faster evaluation)
4. Available imaging (having MRI/angiography ready expedites decision-making)

Avoid Common Pitfalls

• Don't wait for "routine" referral processing in an 18-year-old with seizures—direct communication is appropriate 1, 7
• Don't delay imaging while waiting for consultation; obtain MRI and arrange angiography concurrently 1, 4
• Don't assume deep location means "inoperable"—modern combined approaches (embolization, surgery, radiosurgery) can treat complex AVMs 1
• Don't underestimate seizure impact—achieving seizure freedom is a critical outcome that significantly affects quality of life 3, 6

If Neurosurgery Delays

• Emphasize that 83-90% of patients achieve excellent seizure control after surgery, with many discontinuing anticonvulsants 1, 8
• Note that early surgery prevents secondary epileptogenesis and improves long-term outcomes 7
• Reference that seizure control correlates with shorter seizure duration before surgery (90% excellent results when seizure duration ≤1 year) 7

Seizure Management Pending Evaluation

• Optimize anticonvulsant therapy while awaiting neurosurgical evaluation 1, 3
• Document seizure frequency, type, and medication response to guide surgical planning 8, 7
• Consider neurology co-management if seizures are medication-refractory 3