Hybrid surgery for coexistence of cerebral arteriovenous malformation and primitive trigeminal artery: A case report and literature review

Abstract

The primitive trigeminal artery (PTA), an abnormal carotid-basilar anastomosis, forms the vascular anomaly connection between the internal carotid artery and vertebrobasilar system. Rarely, PTA can be complicated by several other cerebrovascular disease, including arteriovenous malformations (AVMs), intracranial aneurysms, moyamoya disease, and carotid-cavernous malformations. Herein, we reported a rare case of PTA combined with an AVM in a male patient. The patient was a 28-year-old male with epileptic seizures at the onset of symptoms. Magnetic resonance imaging showed abnormal signal foci and localized softening foci formation with gliosis in the right parietal temporal lobe. Furthermore, using a digital subtraction angiogram (DSA), it was found that an abnormal carotid-basilar anastomosis had developed through a PTA originating from the cavernous portion of the right internal carotid artery (ICA) and a large AVM on the surface of the right carotid artery. The lesion of AVM tightly developed and draining into superior sagittal sinus. A hybrid operating room was used for the surgery. The main feeding arteries of the AVM originating from three major arteries, including the right middle cerebral artery, the right anterior cerebral artery, and the right posterior cerebral artery, were clipped and subsequently, then the AVM was thoroughly removed. The intraoperative DSA showed that the AVM had been resected completely. Postoperative pathological examination of the resected specimen indicated the presence of an AVM. The patient recovered well after surgery and has been symptom-free for more than 3 months. In summary, the pathogenesis of the coexistence of PTA and AVM remains unknown. As highlighted in this case report, hybrid surgery can be used to remove AVMs and can improve the patients' prognosis. To our best knowledge, this is the first case in the literature of successful AVM treatment using hybrid surgery.

Keywords: case report; cerebral arteriovenous malformation; hybrid surgery; literature review; primitive trigeminal artery.

Figure 1

In the right parietotemporal lobe, an irregularly circular space-occupying lesion was found with slightly long T1 shadows (A). T2-weighted image shows a parietotemporal lesion with mixed signal characteristics (B). Enhanced MRI shows heterogeneous enhancement in the right parietotemporal lobe (C). The primitive trigeminal artery arose from the cavernous sinus segment of the right ICA (D). Initial right internal carotid artery injections, anteroposterior (E) and lateral views (F), show shunted flow to the cavernous sinus (arrow). Anteroposterior and lateral projection angiogram shows a right parietotemporal AVM supplied by the right middle cerebral artery drainage into the superior sagittal sinus (E,F, dashed oval). 3-dimensional (3D) DSA arterial phase indicates in the lateral projection showing AVM lesion with 42.8 mm in size and PTA obtained after right internal carotid artery injection (G). Fused image of 3D DSA demonstrates the flow of the right ICA (blue), VA (red) (H).

Figure 2

Intraoperative angiography demonstrates subsequent injection of Onyx18 with obliteration of the AVM (A). Lateral view of right ICA angiogram demonstrates the presence of residual arteriovenous malformation (dashed oval) with an early draining vein (arrow) (B). The feeding artery arteries and main draining veins were isolated and resected (C,D, arrows). Intra-operative image shows lesion excised during surgery (E). Postoperative anteroposterior projection angiograms following resection demonstrate the obliteration of the AVM (F). Postoperative Contrast CT shows no obvious significant ischemic or hemorrhage changes (G). Follow-up 3D DSA shows the complete disappearance of AVM (H).