PMC10159302_01
(a) Computed tomography scan on admission showing subcortical hematoma in the left frontal region. (b) Pre-embolization digital subtraction angiography (DSA) anteroposterior images showing a microarteriovenous malformation (AVM) fed by the central artery of the middle cerebral artery. (c) Intraoperative photograph showing that the AVM is not exposed in the cerebral cortex. We dissected the cerebral sulci to find the lesion (dotted line) but with failure. The solid line indicates the sulcus located just above the lesion according to intraoperative ultrasonography (IUS) at the second resection surgery. (d) DSA, during endovascular embolization showing that the lesion is embolized with Onyx. (e) IUS showing that the embolized compartment of the AVM presents as a highly echogenic lesion with acoustic shadow formation. (f) Intraoperative photograph after dissecting the sulcus just above the lesion, showing that an embolized vessel is confirmed (arrow).
SNI-14-146-g001.jpg
PMC10159302_01_SNI-14-146-g001.jpg
F1
Computed tomography (CT) revealed subcortical hemorrhage in the right frontoparietal cerebrum [Figure 1a]. Digital subtraction angiography (DSA) showed a micro-AVM fed by the central artery of the middle cerebral artery (MCA), which was classified as an SMG II AVM [Figure 1b]. Since the AVM was not exposed in the cerebral cortex, we dissected the neighborhood cerebral sulci blindly to find the lesion, but with failure [Figure 1c]. Therefore, we embolized the AVM as a presurgical procedure [Figure 1d] and attempted AVM resection again. During direct surgery, the IUS demonstrated an Onyx-embolized AVM [Figure 1e]. Using this ultrasonographic finding as a marker for the site, we dissected the sulcus slightly above the lesion and directly confirmed the vessels embolized with Onyx [Figure 1f].
PMC10159302_02
(a) Computed tomography scan on admission demonstrating a subcortical hematoma in the left frontal region. (b) Pre-embolization digital subtraction angiography (DSA), anteroposterior images showing a microarteriovenous malformation (AVM) fed by the central artery of the middle cerebral artery. (c) DSA, during endovascular embolization, showing that part of the lesion was embolized presurgically with Onyx. (d) Intraoperative ultrasonography (IUS) showing abnormal vessels embolized with Onyx as well as intracerebral hematoma (*). (e) Intraoperative photograph showing that the AVM is not exposed in the cerebral cortex. The solid lines indicate the sulcus located just above the lesion according to the IUS. (f) Intraoperative photograph after dissecting the sulcus just above the lesion, showing that an embolized vessel is confirmed (arrow).
SNI-14-146-g002.jpg
PMC10159302_02_SNI-14-146-g002.jpg
F2
A CT scan showed a left subcortical hemorrhage [Figure 2a]. DSA revealed a micro-AVM fed by the central artery of the MCA [Figure 2b]. IUS. IUS revealed abnormal vessels that were clearly embolized with Onyx [Figure 2d] and indicated the correct location of the nidus. We dissected the sulcus, in which the nidus was present [Figure 2e] and confirmed the presence of an embolized feeder in the sulcus [Figure 2f].