PMC10408606_01
Preoperative clinical imaging of Case 1 (a) brain computed tomography shows intraventricular hemorrhage and acute hydrocephalus. (b and c) The left ICA angiography shows ventricular AVM fed by the left AChoA and the medial striate artery. (d and e) The left VA angiography shows AVM fed by the left LPChoA and MPChoA. The AVM drains into the internal cerebral vein. White arrowheads show the nidus of the AVM. (f and g) 3D-volume rendering (VR) fusion images (f: A-P, g: lateral view) reconstructed from 3DRA of ICA (pink) and VA (yellow). An intranidal aneurysm was revealed (AN). The asterisk indicates the choroidal point of the AChoA. (h-j) The maximum intensity projection fusion images (h: axial, I coronal, and j: sagittal view) reconstructed from 3D-RA of ICA (white) and VA (yellow). The AVM is located in the body of the caudate. The intranidal aneurysm is within the ventricle. 3D: Three-dimensional, 3D-RA: Three-dimensional rotational angiography, AChoA: Anterior choroidal artery, A-P: Anterior-posterior view, AVM: Arteriovenous malformation, ICA: Internal cerebral artery, Lat: Lateral view, LPChoA: Lateral posterior choroidal artery, MPChoA: Medial posterior choroidal artery, VA: Vertebral artery.
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IVH and acute obstructive hydrocephalus [Figure 1a]. In addition, cerebral angiography showed 1.2 cm-sized AVM nidus, fed by the left AChoA, medial striate artery, medial posterior choroidal artery (MPChoA), and lateral posterior choroidal artery (LPChoA), which drain into the internal cerebral vein (ICV) through the superior choroidal vein (Spetzler-Martin grade II) [Figures 1b-e]. A volume rendering image showed an intranidal aneurysm to be the cause of the rupture [Figures 1f and g]. Maximum intensity projection images, which were reconstructed from three-dimensional rotational angiography (3D-RA), showed an AVM located in the caudate body and an exposed intranidal aneurysm on the left anterior horn ventricular wall [Figures 1h-j].
Embolization of the AVM through the MPChoA and AChoA (Case 1) (a) VR image reconstructed from the 3D-RA of the VA. The AVM is fed by the MPChoA and the LPChoA from the left PCA P2 segment. (b, c) Fluoroscopic and DSA of the selective microcatheter injection. The microcatheter was advanced to the MPChoA plexal segment. (d) Image of the NBCA glue casting injected from the MPChoA. (e) The VA angiography shows the disappearance of AVM from the MPChoA and LPChoA after embolization. (f) VR image reconstructed from the 3D-RA of the ICA. The AVM is fed by the AChoA (pink) and the medial striate artery from the ICA. (g and h) Fluoroscopic and DSA of the microcatheter injection. The microcatheter was advanced to the AChoA plexal segment. Black arrowheads show the choroidal point of the AChoA. (i) Image of the NBCA glue casting injected from the AChoA with slight reflux. (j) ICA angiography shows the disappearance of the AVM after embolization. White and black arrows show the microcatheter's tip and the reflux of the embolic agent, respectively. There is an aneurysm in the nidus (AN). 3D-RA: Three-dimensional rotational angiography, 3D-VR: Three-dimensional volume rendering, AchoA: Anterior choroidal artery, AVM: Arteriovenous malformation, DSA: Digital subtraction image, ICA: Internal carotid artery, Lat: Lateral view, LPChoA: Lateral posterior choroidal artery, MPChoA: Medial posterior choroidal artery, NBCA: n-butyl-2-cyanoacrylate, PCA: Posterior cerebral artery, PChoA: Posterior choroidal artery, VA: vertebral artery.
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A Magic 1.2FM flow-guided microcatheter (Balt, Montmorency, France) was navigated to the left MPChoA and advanced distally near the nidus [Figures 2a and b]. ICV without reflux to the normal territory [Figure 2c]. In addition, embolization was performed with 0.1 mL of 25% n-butyl-2-cyanoacrylate (NBCA) [Figure 2d]. The NBCA injected from the MPChoA even penetrated the nidus region supplied by the LPChoA, and the AVM was not visualized from the PChoA, resulting in partial occlusion [Figure 2e]. After microcatheter injection confirmed that there was no reflux to the normal territory, embolization was performed with 0.08 mL of 20% NBCA [Figures 2f-i], with slight glue reflux. Angiography revealed complete obliteration of the AVM after the second injection [Figure 2j], and no neurological deficits were observed after embolization.
PMC10408606_02
Preoperative clinical imaging of Case 2 (a) brain computed tomography shows intraventricular hemorrhage and acute hydrocephalus. (b-e) Right ICA angiography shows the AVM fed by AChoA and LPChoA, draining into the inferior ventricular vein to the basal vein of the rosenthal, tentorial sinus, and transverse-sigmoid sinus junction. (f-i) 3D-VR images reconstructed from the ICA (f and g: Cranial, h and i: Lateral view) shows the AVM fed by LPChoA originating from the Pcom (pink) and AChoA (yellow). (j) Fusion image of 3D-RA of ICA and time-of-flight magnetic resonance angiography shows the AVM located within the trigone of the right ventricle. White arrowheads show the nidus of the AVM. 3D-RA: Three-dimensional rotational angiography, 3D-VR: Three-dimensional volume rendering, A-P: Anterior-posterior view, AChoA: Anterior choroidal artery, AVM: Arteriovenous malformation, ICA: Internal carotid artery, Lat: Lateral view, LPChoA: Lateral posterior choroidal artery, Pcom: Posterior communicating artery.
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A brain CT scan showed IVH and acute obstructive hydrocephalus [Figure 3a], and CT angiography showed a brain AVM. Cerebral angiography showed an AVM located in the trigone of the right lateral ventricle, which was fed by AChoA and LPChoA and was draining into the inferior ventricular vein to the basal vein of the rosenthal, tentorial sinus, and transverse-sigmoid sinus junction (SpetzlerMartin grade II) [Figures 3b-j].
Embolization of AVM through the right AChoA and LPChoA (Case 2) (a and b) Selective angiography of the AChoA. The microcatheter (dotted line) is advanced to the AChoA plexal segment. Black arrowheads show the choroidal point of the AChoA. Selective angiography shows AVM draining into the transverse-sigmoid sinus junction through inferior ventricular vein, basal vein of the rosenthal, and tentorial sinus. (c and d) Fluoroscopic images of the Onyx cast injected from the AChoA. (e and f) The microcatheter (dotted line) is advanced to the right posterior cerebral artery through the Pcom. Selective angiography shows the AVM fed by the LPChoA. (g and h) Fluoroscopic images of the NBCA cast injected from the LPChoA. (i) ICA angiography after embolization shows residual lesion with flow reduction. (j) The AVM disappeared on a follow-up angiography 3 years after gamma knife surgery (GKS). White and black arrows show the microcatheter's tip and the reflux of the embolic agent, respectively. 3D-VR: Three-dimensional volume rendering, A-P: Anterior-posterior view, AChoA: Anterior choroidal artery, AVM: Arteriovenous malformation, ICA: Internal carotid artery, Lat: Lateral view, LPChoA: Lateral posterior choroidal artery, NBCA: n-butyl-2-cyanoacrylate, PChoA: Posterior choroidal artery, Pcom: Posterior communicating artery.
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AChoA and distally beyond the choroidal point [Figures 4a and b]. In total, 0.19 mL of Onyx18 (eV3 Inc.) was injected, and it penetrated the nidus without excessive Onyx reflux [Figures 4c and d]. After that, the microcatheter was removed smoothly. Subsequently, a Magic 1.2FM microcatheter was advanced to the right LPChoA through the posterior communicating artery and distally closer to the nidus [Figures 4e and f]. AVM [Figures 4g and h]. NBCA partly penetrated the draining side beyond the nidus. Angiography showed that partial obliteration resulted in a significant flow reduction [Figure 4i]. The AVM disappeared on a follow-up angiography 3 years after GKS without latency period rebleeding [Figure 4j].