Cerebral Arteriovenous Malformation With Ipsilateral Middle Cerebral Artery Occlusion: A Case Report

Abstract

We report the case of a 29-year-old man who presented with a sudden headache. Computed tomography showed a small intraventricular hemorrhage in the left lateral ventricle. Cerebral angiograms suggested rupture of a coexisting feeder aneurysm in the left temporal cerebral arteriovenous malformation (AVM). The left proximal middle cerebral artery, a major feeding artery, was occluded near the AVM, with development of abnormal blood supply, such as in moyamoya-like vessels to the nidus. After endovascular embolization of the coexisting feeder aneurysm and feeding arteries, the patient underwent volume-staged Gamma Knife radiosurgery (GKS). Follow-up angiograms performed 4.5 years after the last GKS confirmed complete disappearance of the AVM. Around 4.8 years after GKS, the patient required surgical intervention to develop delayed cyst formation; however, the postoperative course was uneventful.

Keywords: cerebral arteriovenous malformation; cyst formation; feeder aneurysm; gamma knife radiosurgery; occlusion of the major feeding artery.

Figure 1. Axial image of a noncontrast computed tomography scan at the onset showing a small intraventricular hemorrhage (black arrow) at the left lateral ventricle.

Figure 2. Contrast-enhanced computed tomography showing a cerebral arteriovenous malformation (black arrow) with a maximum diameter of 32 mm within the left temporal lobe.

Figure 3. Pre-embolization DSA images of the feeders, nidus, and drainers.

(A) Anteroposterior views of the ICAG showing a prominent feeder from the left anterior cerebral artery, MCA, and AchA. The proximal left MCA to the nidus exhibits occlusion with moyamoya-like vessel around it (black arrow). (B) Lateral views of the pre-embolization DSA image demonstrating a feeder aneurysm of AchA (black arrow). The proximal left MCA to the nidus exhibited occlusion with small moyamoya vessel-like arteries around it without steno-occlusive lesions around terminal portions of the internal carotid artery (ICA). (C) Anteroposterior views of the left external carotid angiography showing a prominent left middle meningeal artery feeder (black arrow). (D) Anteroposterior views of the right vertebral angiography showing a prominent left posterior cerebral artery feeder (black arrow). (E) Lateral views of the left ICAG showing venous drainage into the left transverse sinus (black arrow) through the two ipsilateral superficial cerebral veins via the sphenopetrous vein. DSA, digital subtraction angiography; ICAG, internal carotid angiography; MCA, middle cerebral artery; AchA, anterior choroidal artery

Figure 4. Snapshot of the first target in blue circles (black arrowheads) and the second target in yellow circles (black arrows) of Gamma Knife.

(A-C) Axial, coronal, and sagittal images and 3D reconstruction showing the dose plan of the first GKS. The prescribed dose was 17 Gy (yellow line). (D-F) Axial, coronal, and sagittal images and 3D reconstruction showing the dose plan of the second GKS. The prescribed dose was 17 Gy (yellow line). Blue line shows the target of the first GKS. 3D, three-dimensional; GKS, Gamma Knife radiosurgery

Figure 5. Axial magnetic resonance image showing a Gd-DTPA-enhanced lesion (black arrow) with perifocal edema appeared in the tip of the left temporal lobe.

Gd-DTPA, gadolinium-diethylenetriaminepentaacetic acid

Figure 6. DSA image 4.5 years after GKS demonstrated no abnormal blood vessels other than the left M1 occlusion (black arrows).

(A) Anteroposterior view of DSA. (B) Lateral view of DSA. DSA, digital subtraction angiography

Figure 7. Axial magnetic resonance image of T2-weighted image showing perifocal edema (black arrow) getting bigger than 22 months ago, when the cyst was diagnosed.