PMC4663032_01
Angiograms obtained before hemorrhage. Anteroposterior view of the right internal carotid artery (A), the left internal carotid artery (B), and the left vertebral artery (C) angiogram showing a left parieto-occipital arteriovenous malformation fed by numerous cortical branches with an intranidal aneurysm (arrow).
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F1
A subsequent workup revealed a Spetzler-Martin Grade 5 AVM with a 7.3-cm maximum diameter in the left parieto-occipital area (Fig. 1A-C).
A: Computed tomography (CT) on admission showing intracerebral hemorrhage around the left basal ganglia and the left parietal lobe with intraventricular extension. B: CT obtained on day 3 showing the enlargement of the intracerebral hematoma.
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F2
On arrival, she was alert, and a computed tomography (CT) revealed left parietal intracerebral hemorrhage with intraventricular extension (Fig. 2A). On day 3, her right hemiparesis suddenly progressed to complete paralysis, and a CT scan revealed rebleeding with an increase in the size of the intracerebral hematoma (Fig. 2B).
Axial non-enhanced (A) and gadolinium-enhanced (B) T1-weighted image obtained on day 2 revealing the linear enhancement of the outer surface of the thickened vessel wall of the intranidal aneurysm (arrows). Sagittal gadolinium-enhanced T1-weighted image (C) showed the intranidal aneurysm located adjacent to the intracerebral hematoma (arrowheads). The outer rim of the hematoma was iso-intensity. Axial gadolinium-enhanced T1-weighted image obtained 5 days after the targeted embolization (D) showing total thrombosis of the intranidal aneurysm. Axial gadolinium-enhanced T1-weighted image obtained 10 months after the targeted embolization (E) showing decrease of the vessel wall enhancement and shrinkage of the intranidal aneurysm (arrow).
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F3
T1-weighted imaging before and after intravenous administration of Gd, we used three-dimensional (3D) spoiled gradient-recalled acquisition, repetition time (TR) 8.5 msec, echo time (TE) 1.9 msec, flip angle 15 , matrix 384 x 288, field of view 22 cm, and slice thickness 1.2 mm with zero-fill interpolation. The T1-weighted imaging with Gd enhancement demonstrated linear enhancement along the outer surface of the thickened wall of the intranidal aneurysm (Fig. 3A-C). Postoperative MRI revealed that the intranidal aneurysm had completely thrombosed (Fig. 3D).
A: Right external carotid angiogram obtained before targeted embolization showing that the intranidal aneurysm (arrow) is mainly fed by the right middle meningeal artery through the falx. B: Right external carotid angiogram after the embolization showing no contrast filling of the aneurysm. C: Right internal carotid angiogram after the embolization also showing no contrast filling of the aneurysm.
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F4
The intranidal aneurysm was mainly fed by the right middle meningeal artery and the superficial temporal artery through falx (Fig. 4A). The right external and internal carotid angiography after the embolization showed no filling of the intranidal aneurysm (Fig. 4B, C).