Recurrence of a cerebral arteriovenous malformation following complete surgical resection: A case report and review of the literature

Abstract

Background: Angiography-confirmed complete resection of an arteriovenous malformation (AVM) has traditionally been considered curative. However, recurrence of AVM following angiographically proven complete resection does exist, especially in children. This rare occurrence has been reported 29 times in the English language literature. Although recurrence may be asymptomatic, many reported cases result in epilepsy or intracranial hemorrhage anywhere from 0.5 to 9 years following complete resection. We report a rare case of AVM recurrence that became symptomatic 16 years after complete resection. We review the literature and discuss the relevance of performing follow-up imaging to detect AVM recurrence.

Case description: An 8-year-old girl presented with a right occipital hemorrhage with intraventricular extension from a ruptured AVM of the right occipital lobe. She underwent AVM resection through a right occipital craniotomy. Postoperative angiography confirmed complete resection and she made an uneventful recovery. Sixteen years later, she presented with a 2-month history of headaches, nausea and dizziness. Angiography revealed recurrence of the AVM which was completely resected, as documented on postoperative angiography.

Conclusion: In children, an AVM may recur after angiography-proven complete resection. Recurrence may be due to persistence and growth of an initially angiographically occult arteriovenous shunt left in place during surgery or the development of a new AVM. In addition to obtaining follow-up angiography 6-12 months after surgery, a late angiography 5 years after resection may be warranted in patients at risk for recurrence. Asymptomatic recurrence detection allows treatment and may prevent the morbidity associated with intracranial hemorrhage.

Keywords: Arteriovenous malformation; cerebral hemorrhage; postoperative angiography; recurrence.

Figure 1

(a, b) Head CT showing a right occipital intraparenchymal hemorrhage with extension into the right lateral and fourth ventricle

Figure 2

MRI with axial T1WI (a), axial T2WI (b) and sagittal T1WI (c) images, obtained 3 months after hemorrhage, showing resorption of the hematoma and residual encephalomalacia in the right occipital lobe

Figure 3

Anteroposterior (AP, a) and lateral (b) right internal carotid artery angiogram, performed 4 months after hemorrhage, showing a right occipital Spetzler-Martin grade III arteriovenous malformation (4 × 3 × 1.5 cm) with feeders from the posterior parietal and angular branches of the middle cerebral artery and early superficial cortical venous drainage to the right transverse sinus. There were no feeders arising from the external carotid artery or vertebro-basilar system

Figure 4

AP (a) and lateral (b) right common carotid artery angiogram, performed 17 days after surgery, showing no residual arteriovenous malformation

Figure 5

CTA (a) with axial reconstruction (b), obtained 16 years after arteriovenous malformation (AVM) resection, showing recurrence of the AVM in the anterior portion of the resection cavity in the right occipital lobe

Figure 6

AP (a) and lateral (b) right common carotid artery angiogram showing recurrence of a Spetzler-Martin grade III (3 × 3.5 × 3.5 cm) arteriovenous malformation with middle cerebral artery branch feeders and drainage through a cortical vein to the SSS. Postoperative angiography (c) shows complete resection