PMC6744769_01
(a) Axial T1-weighted magnetic resonance imaging (MRI) with gadolinium and (b) MR angiography show the arteriovenous malformations (AVM) located in the right frontal operculum and anterior insula with prominent venous drainage in the interpeduncular cistern. (c) Coronal T1 MRI shows medial extension of the AVM. (d) Anteroposterior (AP) angiogram of the right common carotid shows the AVM and its venous drainage into a tortuous basal vein of Rosenthal and vein of Galen. (e) AP of the right internal carotid (ICA) shows the AVM. (f) Lateral projection of the right ICA angiogram shows filling from middle cerebral artery branches.
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F1
The venous drainage followed a deep pattern into a dilated and tortuous right basal vein of Rosenthal to the vein of Galen and ultimately into the straight sinus [Figure 1].
Lateral (a) and anteroposterior (AP) (b) right external carotid angiogram showing filling of the arteriovenous malformations (AVM) through the middle meningeal (MMA), accessory meningeal (AMA), and sphenopalatine (SPA) arteries. Superselective catheterization of the SPA (c), AMA (d), MMA (e), just before Onyx-18 embolization. Lateral (f) and AP (g) projections of the external carotid artery post-embolization with Onyx-18 not showing any filling of the AVM from the external circulation.
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F2
In the first stage, superselective catheterization of the right middle meningeal, accessory meningeal, and sphenopalatine arteries was performed using a Marathon microcatheter (Medtronic, Minneapolis, USA) and a Synchro 10 microwire (Stryker, Kalamazoo, USA) [Figure 2].
(a) Lateral right internal carotid (ICA) angiogram in early to midarterial phase showing filling of the nidus from opercular middle cerebral artery branches. (b) Superselective catheterization of opercular branches in preparation for injection of Onyx- 18. (c) Lateral ICA projection after partial embolization of the arteriovenous malformations (AVM). Intraoperative AP (D) and lateral (E) common carotid angiogram showing complete resection of the AVM. The anterior cerebral circulation is not seen in this injection since it fills from the contralateral side.
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F3
In the second stage, the next day, the feeding branches of the opercular segment of the MCA were accessed with a Scepter balloon-guided microcatheter (MicroVention Inc., Tustin, USA) and a Synchro 2 microwire [Figure 3]. AVM. An intraoperative control angiogram confirmed complete obliteration of the AVM [Figure 3d and e].