Presentation
Sudden onset of repeated seizures first occurring at age 30.
Patient Data
An enhancing serpiginous lesion is demonstrated in the left temporal lobe. There is dilatation of the left middle cerebral artery (probably the feeding artery). Multiple enlarged contrast filled vessels are also seen coursing towards the superior sagittal sinus and the straight sinus (probably draining veins).
These features are suggestive of cerebral arteriovenous malformation.
T2/FLAIR sequences show multiple serpiginous flow-voids with nidus within the left temporal lobe of the brain giving the bag of black worms appearance (maximum diameter of the nidus is 49 mm). No evidence of local mass effect or hemorrhage is seen.
MRA shows a feeding vessel from the M1 segment of the left middle cerebral artery. Multiple large draining veins are seen taking a tortuous course from the nidus to join the superior sagittal sinus at different points. Another large tortuous draining vein coursing through the left ambient and quadrigeminal plate cisterns to join the straight sinus is seen. The other intra and extracranial vessels are normal in caliber and demonstrate normal flow patterns.
Features are those of cerebral arteriovenous malformations with nidus in the left temporal lobes, having an arterial feeder from M1 branch of left MCA and multiple dilated draining veins coursing superiorly to the superior sagittal sinus - superficial vein and posteriorly to the straight sinus - deep vein. (Spetzler-Martin grade 3)
No evidence of intracranial hemorrhage or mass effect seen.
Case Discussion
The patient is 30 years old which is the mean age of diagnosis of AVMs and presented with sudden onset of seizures which is a common presenting symptom (20%).
Imaging findings revealed a solitary nidus of AVM in the left temporal lobe with feeding artery from the MCA and a unique draining pattern into both the superficial and deep cerebral venous systems.
Based on the size of the nidus (about 49mm), its presence in a non-eloquent locus on the brain (temporal lobe) and draining into both superficial and deep cerebral venous systems, a grade 3 Spetzler-Martin was awarded.
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