PMC5009574_01
Angiographic images: digital subtraction angiography (DSA) (posterioranterior view) (a) and DSA (lateral view) (b) 6 years before the AVM rupture; preoperative axial computed tomography (c) large basal ganglia-putamenal intracerebral hemorrhage
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AVM [Figure 1a and b]. At the age of 18, she admitted to our hospital with loss of consciousness and left hemiparesis (mRS score 5). A computed tomography (CT) scan revealed large intracerebral hemorrhage [Figure 1c] due to ruptured arteriovenous malformation.
Intraoperative photography during second operation: Total temporary clipping - A1, supraclinoid segment of internal carotid artery and anterior choroidal artery (P2 segment not visualized)
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We used total temporary clipping under mild hypothermia (33 C) for almost 4 hours; P2 segment of PCA, A1 segment of anterior cerebral artery, anterior choroidal artery (AChA), and the supraclinoid segment of internal carotid artery (ICA) [Figure 2].
Postoperative images after the 2nd operation: axial ST scan (a) air instead of main part of arteriovenous malformation (AVM); digital subtraction angiography (posterioranterior view) (b) medial and later residual parts of AVM (arrows); axial diffusion weighted imaging scan (c); only focal ischemia adjacent to remnant part in basal ganglia
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AVM underwent removal [Figure 3a]. A postoperative angiogram demonstrated remaining medial and some of the lateral parts of AVM [Figure 3b]. MRI with diffusion-weighted imaging (DWI) performed next day showed a lack of global ischemia [Figure 3c].
Postoperative angiographic images after the 4th embolization: Digital subtraction angiography (DSA) (posterioranterior view) (a) no filling of arteriovenous malformation through middle cerebral artery; DSA (lateral view) (b) small residual part filling through branch of posterior cerebral artery (arrow)
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Residual part filling via MCA was completely occluded, however, small residual filling via PCA remained [Figure 4a and b].
Postoperative images after the 4th operation: Axial ST scan (a) occluded part of the arteriovenous malformation (AVM); digital subtraction angiography (lateral view) through the middle cerebral artery (b) and through posterior cerebral artery (c) - AVM not filling
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Eventually, AVM was completely occluded [Figure 5a-c].
The patient - five years after initial surgery
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These symptoms gradually improved, and 5 years after her initial surgery, she could walk without assistance, however, visual changes and memory difficulties remained (mRS score 3) [Figure 6].