Arteriovenous Malformation (AVM) CASE Studycase Presentation: A 40-year-old male patient presented with new onset of grand mal seizures over a two-month period. the initial brain mri from an outside hospital demonstrated enlarged vessels involving the right temporal lobe consistent with an AVm.
AVM EMBolIzAtIoN ProCEdurE
Embolization is done through a microcatheter advanced into feeding arteries.
From there, embolic material is injected into the nidus over a certain period
of time under fluoroscopic guidance. Onyx® is an FDA-approved alcohol-
based liquid and cohesive embolic material now routinely used to embolize
cerebral vascular lesions. Each Onyx injection takes 30 to 60 minutes.
General y, two to three feeding arteries are used for each embolization,
depending on the microcirculation and anatomical structure of the AVM.
Each procedure takes approximately two to three hours and is done under
general anesthesia. The patient typical y spends one to two days in the
intensive care unit for neurological examination and close observation of
Diagnostic imaging found a
Spetzler-martin grade i i AVm with a diameter
of 3 cm x 4 cm, feeding from branches of
the right middle cerebral artery, the anterior
choroidal artery and the posterior cerebral
artery. the venous drainage involved the
superficial and deep venous drainage system.
in addition, several direct arteriovenous shunts
were noted. no arterial or venous aneurysms
fol owing two embolization
procedures, imaging shows the residual AVm
and the “onyx cast” or embolic material that
was injected. the onyx embolizations closed
of more than 90 percent of the nidus without
compromising the venous outflow of normal
the postoperative ct scan
residual embolic material and postoperative
changes are seen. the transcranial Doppler
flow studies demonstrated normal antegrade
flow in the right middle cerebral artery.
FolloWInG ReFeRRal to santa Barbara neuroscience
of the injected onyx material. The second option would
Institute, the patient was started on keppra (levetiracetam)
involve radiosurgery—utilizing either Gamma knife®, a
to prevent additional seizures, and a diagnostic cerebral
linear accelerator, or cyberknife®—to deliver high-dose focal
angiography was performed. (The results of the brain MRI
radiation to the residual nidus while shielding the rest of the
and the cerebral angiogram are illustrated in Figure 1
patient then underwent two onyx® embolization procedures
In this case, surgical resection was the better choice for
scheduled approximately one week apart. To reduce the
several reasons: the patient was young and otherwise healthy;
perioperative risks for hemorrhage, only 30 to 45 percent of
the aVM surgical risks were low after more than 90 percent
the nidus (center) of the aVM was embolized in each session.
of the nidus was occluded with embolic material; and the
This patient received a total of three injections through
location of the aVM (right side and temporal lobe) was
branches and feeding arteries of the right middle cerebral
artery and one injection via the basilar artery and the posterior
a right-sided craniotomy and resection of the aVM was
cerebral artery. Figure 2
demonstrates a microcatheter
performed using standard neurosurgical and microsurgical
injection and portions of the nidus prior to embolization. The
techniques. Intraoperative advantage was taken using
final angiogram shows less than 10 percent of residual nidus.
BrainlaB frameless navigation to localize the residual nidus
This portion of the aVM was not embolized, as it would
and the draining veins. The procedure was uneventful.
have been at significant risk to the patient. This particular
standard aVM protocols included a postoperative angiogram
area is fed from the anterior choroidal artery. This artery
to be certain the entire aVM was removed and confirm
carries blood not only to the aVM but also to very important
no angiographic signs of early venous drainage. Figure 3
normal brain structures, such as the internal capsule and the
demonstrates the postoperative angiogram without any
basal ganglia. Treating this portion of the aVM with surgical
resection or radiosurgery would be significantly safer.
The patient recovered very well from the surgery and was
discharged on postoperative day five without neurological deficits. he returned to work approximately four weeks
aVM eradICatIon optIons
after the second embolization, a discussion with the patient after surgery.
and his family took place on two options for completely
To access an in-depth video presentation of this case by
eliminating the aVM. The first option would be a craniotomy
Dr. Zauner with 3-D rotational angiograms and other cases, and
and surgical resection of the residual nidus, including most
additional images, visit our website at www.sbni.org.
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