PMC8452862_01
(A) AP roadmap image of co-dominant right VA, with tortuous origin (arrow) from the subclavian artery. (B) AP roadmap of left VA origin (arrow) and proximal cervical course of the artery. The artery of cervical enlargement is also seen (arrowhead). (C) AP angiogram from a right VA injection, with opacification of the AVM nidus (arrowhead), with competitive flow from the left VA. (D,E) AP and lateral arterial phase images from a left VA injection, demonstrating the AVM nidus (arrowheads) in the superior aspect of the right cerebellar hemisphere. (F-H) Reconstruction of 3D DSA data in axial (F), Sagittal (G), and coronal (H) planes, demonstrating the AVM nidus (arrowheads).
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F1
AVM was supplied primarily through branches of a hypertrophied right superior cerebellar artery (SCA), with lesser arterial supply provided by distal branches of the right posterior inferior cerebellar artery (PICA) (Figure 1). A single short superficial cerebellar vein drained the AVM into a right cerebellar tentorial vein, and then into the right transverse sinus.
(A,B) AP Roadmap images of the left VA, before (A) and after (B) advancement of the five Fr guide sheath into the mid cervical left VA, distal to the origin of the artery of cervical enlargement (arrowheads). The position of the tip of the guide sheath is marked by the arrow. (C,D) Lateral and AP views of a right superior cerebellar artery microcatheter injection, during embolization of the AVM. (E,F) Final cast of the Onyx (arrowheads) within the AVM nidus. (G,H) Final AP and lateral arterial phase images of the posterior circulation, from a left VA injection, demonstrating the residual nidus (arrows). (I,J) Lateral and AP images from the final left VA injection prior to removal of the guide sheath, demonstrating patency of the ASA (arrowheads).
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F2
There was good flow around the five French sheath without evidence of any contrast stagnation to suggest flow compromise or occlusion of the VA (Figure 2).
MRI Cervical Spine, performed the day following the embolization. (A,B) Sagittal T2W images demonstrating abnormal increased T2 signal in the spinal cord (arrows). (C) Sagittal Diffusion Weighted image demonstrating abnormal diffusion restriction in the Cervical Spinal cord (arrows). (D,E) Axial GRE T2W images demonstrating abnormal increased signal in the central Gray matter, or "owls eye" sign. (F) Axial TSE T2W image demonstrating the "owls eye" sign.
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F3
Additionally, new signal abnormality had developed at the C5-C6 level, without associated cord expansion (Figure 3).
Timeline of events post-procedure.
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F4
Figure 4 demonstrates the timeline of the events within 24 h after the procedure.