Right Cerebral Arteriovenous Malformation from A3 segment: Case report and Review of the Literature D.Gunia E.Ekvtimishvili Harshavardhan.B

Abstract :

We report a case of 28 year old male who presented with intraventricular hemorrhage visualized in MRI for whom DSA revealed a Right sided Cerebral Arteriovenous malformation arising from right anterior cerebral artery A3 segment which was embolized using histacryl glue.

Introduction :

An arteriovenous malformation is a tangled cluster of vessels, typically located in the supratentorial part of the brain, in which arteries connect directly to veins without any intervening capillary bed. The lesion may be compact, containing a core of tightly packed venous loops, or it may be diffuse, with anomalous vessels dispersed among normal brain parenchyma. In 77% of cases the core, or nidus, of a compact arteriovenous malformation is 2-6 cm in diameter.[1]

Case Report :

A 28 year old male presented with intraventricular hemorrhage, visualized in MRI.

Diagnostic four vessel DSA revealed a right cerebral arteriovenous malformation arising from A3 segment of right anterior cerebral artery which was 2cm in size , non eloquent & draining into superficial veins only & hence Spetzler Martin Grade 1 AVM with two feeders from A3 segment visualized. Treatment plan of embolization with histacryl glue was decided.

On Right Femoral arterial approach, using Magic 1.5 (BALT) microcatheter & Sor 007J (BALT) micro guidewire, embolization with histacryl glue was done with histacryl & lipiodol in a ratio of 1:7. The histacryl glue with lipiodol was injected with the microcatheter in the nidus & thus completely occluding the nidus, draining veins & finally the feeder.

 harSa_gunia

Fig :

  1. Right Internal Carotid Angiogram lateral view showing the Arteriovenous malformation (arrow) arising from the A3 segment.
  2. Right Internal Carotid Angiogram lateral view Showing the feeders (arrows) of the AVM.
  3. Superselective angiogram with the microcatheter intranidal, showing the nidus (black arrow) and the draining veins (white arrows).
  4. Histacryl glue embolization visualized due to the lipiodol contrast medium.
  5. Right Internal Carotid DSA showing the completely occluded AVM (arrow)
  6. Right Internal Carotid DSA lateral view showing the completely occluded AVM.

Discussion :

The cerebral AVM represents a direct communication between arteries and the veins without intervening capillaries, the communicating vascular channels being larger than capillaries yet arbitrarily smaller than fistulas. The nidus represents the central compact tangle of low-resistance vessels constituting the junction of the feeding arteries & the draining veins.

Roughly 30 to 55% of patients present with intracranial hemorrhage, which is most commonly intraparenchymal but may be intraventricular or subarachnoid. AVMs 3cm or less in diameter have been reported to bleed more frequently and to produce larger hematomas than larger AVMs. The second common presentation of cerebral AVMs is sezuires.

A common method of grading cerebral AVMs is the Spetzler-Martin grade.[2] This system was designed to assess the patient's risk of neurological deficit after open surgical resection, based on characteristics of the AVM itself. Based on this system, AVMs may be classified as grades 1 – 5, depending on the total scores. The risk of post-surgical neurological deficit (difficulty with language, motor weakness, vision loss) increases with increasing Spetzler-Martin grade.

size of nidus

  • small (<3cm) = 1
  • medium (3 - 6cm) = 2
  • large (> 6cm) = 3

eloquence of adjacent brain

  • non-eloquent = 0
  • eloquent = 1

venous drainage

  • superficial only = 0
  • deep = 1

Conventional cerebral angiography is the criterion standard for the evaluation of AVMs. The study should include both internal carotid arteries and both vertebral arteries, with sequential evaluation of the arterial, capillary, and venous phases. External carotid arteries should be evaluated for dural contributions. The goal of the study should be to identify the number and location of feeding arteries, the angiographic location and size of the nidus, the shunt type of the lesion (eg, high flow vs low flow), and the pattern of venous drainage (eg, superficial, deep, or mixed).

Embolization is often performed to reduce the flow and size of brain AVMs before surgical resection or radiosurgery, but in some instances , complete cure can be achieved with embolization alone.[3] The glue used for embolization is characterized by instant polymerization when comes in contact with blood. A mass of polymer is visible on X-ray due to contrast medium Lipiodol that is added to glue (histacryl) and injected together.

The treatment will be determined by the size of the AVM and also the location. It is not uncommon to recommend a combination of treatments.

References :

  1. De Biase L, Di Lisi F, Perna S, Spalloni A, Ferranti F, Lucani A, et al. Recurrent episodes of syncope in a patient with cerebral arteriovenous malformation. Clin Ter. Mar-Apr 2007;158(2):147-50.
  2. Mayo Clinic staff (02 2009). "Brain AVM (arteriovenous malformation)-Symptoms". Mayo Foundation for Medical Education and Research. Retrieved 2010-05-18.
  3. Berentein A, Lasjaunias P : Surgical Neuroangiography. New York, Springer-Verlag, 1992
  4. Hagga JR, Dogra VS, Forsting, Gilkeson R C, Hyun Kwon Ha, Sundaram M, CT & MRI of the whole body, Fifth Edition, Cerebral Aneurysms & Cerebrovascular malformations, pages 249 – 263, 2009
  5. Robert A Koenigsberg, DO, MSc, FAOCR; Chief Editor: James G Smirniotopoulos, MD, Brain Imaging in Arteriovenous Malformation, Medscape reference, May 25, 2011
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