PMC5283165_01
Cranial ultrasonography, MRI, and MRA of the patient with pial AVF. (A) Cranial ultrasonography (left temporal lobe): Abnormal blood flow is visible just under the left temporal bone. (B) Cranial MRI (T2-weighted image): A pial AVF at the left sylvian fissure with dilated left middle cerebral artery and venous pouch (flow-void area) is visible on the left temporal lobe. (C) Cranial MRA: An AVF supplied by a single branch of the left middle cerebral artery with an enlarged venous pouch draining to the left sylvian fissure is visible on the left temporal lobe. AVF, arteriovenous fistula; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging.
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A dilated left middle cerebral artery and abnormal blood flow were detected just under the left front-temporal bone on cranial ultrasonography (Fig. 1A). The cranial magnetic resonance imaging and magnetic resonance angiography examinations showed single AV malformation on the left sylvian fissure (Fig. 1B, C), but no focal steal ischemic change was observed in the left cerebral hemisphere.
Clinical course of the patient. Initially, the patient was treated conservatively with diuretics. After 1 month, tachypnea had subsided, but weight gain was still poor. SVC flow of the patient increased to 413 mL/kg/min just before the operation at 62 days of age. After the operation, the SVC flow decreased to 136 mL/kg/min immediately. Thereafter, weight gain improved. The shaded zone shows the normal range of SVC flow, which is from 55 to 111 mL/kg/min. BW, body weight; HR, heart rate; RR, respiratory rate; SVC, superior vena cava.
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The SVC flow, proposed by Kluckow and Evans, of the infant was 117 mL/kg/min, approximately the upper normal limit in term infants (Fig. 2). The SVC flow increased further to 413 mL/kg/min just before the operation (Fig. 2).
Cranial four-dimensional computed tomographic angiography in the patient with pial AVF. Upper part: preoperative images. A pial AVF with a dilated left middle cerebral artery and venous pouch is visible. The venous pouch and drainage veins are already enhanced on arterial phase. Lower part: postoperative images. There is no arteriovenous malformation or abnormal blood perfusion. AVF, arteriovenous fistula.
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Results of the examination showed that a lesion was located in the superficial area of the brain and was suspected to have a pial AVF (Fig. 3).