PMC9360567_01
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).
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Magnetic resonance imaging showed abnormal signal foci and localized softening foci formation with gliosis in the right parietotemporal lobe (Figures 1A-C). Magnetic resonance angiography (MRA) indicated carotid-basilar anastomosis and the presence of vascular malformations in the right parietal temporal lobe (Figure 1D). Further evaluation using DSA revealed an abnormal anastomosis between the carotid and basilar arteries through a PTA originating from the cavernous portion of the right internal carotid artery (ICA) (Figures 1E-H). Vascular malformation is tight, and a large number of fine branching arteries from the frontotemporal branch of the right middle cerebral artery, the right anterior cerebral artery, the right posterior cerebral artery, and the right external carotid artery served as its blood supply (Figures 1E-H).
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).
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Inc., Minneapolis, Minnesota, USA), and confirming continued injection until the feeding artery stasis (Figure 2A). Intraoperative DSA showed a residual AVM with an early draining vein (Figure 2B). The AVM's major feeding artery was clipped, which arose from the right middle cerebral artery, the right anterior cerebral artery, and the right posterior cerebral artery (Figure 2C). The dura was cut under a microscope and observed to be tightly adherent to the brain surface tissue (Figure 2D). No focal regions were observed in the right hemisphere (Figure 2E). DSA was performed immediately after the AVM resection, which showed that the AVM was completely removed (Figure 2F). A 3e-day postoperative computed tomography scan showed good recovery of brain tissue (Figure 2G). On postoperative DSA rightward head rotation, the AVM lesion completely disappeared (Figure 2H).