Presentation
Intermittent headaches and anomia.
Patient Data
Serpiginous malformed vessels in the posterior temporal lobe, suspicious for a cerebral arteriovenous malformation (CAVM).
No other abnormalities.
Findings:
Small nidus (≤3cm) of serpiginous malformed vessels in the left posterior temporal lobe.
Arterial supply is mainly from the peripheral branches (M4) of the middle cerebral artery (MCA) and less from the anterior and posterolateral choroidal arteries.
Venous drainage mainly via two very prominent and multiple other smaller vessels into the superficial middle cerebral vein (SMCV), the superior anastomotic vein (vein of Trolard) and inferior anastomotic vein (vein of Labbé). Possible minor drainage via some tiny vessels into the deep veins (choroid veins).
Impression:
Small cerebral arteriovenous malformation in the left posterior temporal lobe with a compact nidus.
Venous drainage mainly into the superficial veins.
Spetzler-Martin grade 2
Shortly afterwards patient underwent CyberKnife therapy of the small cerebral arteriovenous malformation in the left posterior temporal lobe.
Findings:
Some decrease of the nidus with quite some residual serpiginous vessels.
The two prominent draining veins are more or less unchanged.
Impression:
Status post radiosurgery.
Residual arteriovenous malformation with two draining veins.
Findings:
Hyperintense signal in the posterior periventricular white matter at the location of the previous cerebral arteriovenous malformation (CAVM), with mild contrast enhancement. Very few small, residual serpiginous vessels.
Caliper reduction to a greater and a lesser extent of the two prominent draining veins with one remaining but a smaller draining vessel.
Impression:
Status post radiosurgery with post-radiogenic changes.
Further decrease of the nidus with caliper reduction of the draining veins.
Findings:
Hyperintense signal in the posterior periventricular white matter at the location of the previous cerebral arteriovenous malformation (CAVM), with avid contrast enhancement. No residual serpiginous vessels.
The two draining veins have disappeared.
Impression:
Postradiogenic changes and enhancement after CyberKnife therapy.
Further decrease of the nidus with complete caliper reduction of the draining veins.
Findings:
- small residual contrast enhancement consistent with post-therapeutic changes
- the two draining veins have completely disappeared
Impression:
Minor post-therapeutic changes and gliosis after CyberKnife.
Case Discussion
An example of a cerebral arteriovenous malformation (CAVM) with a small, compact nidus of serpiginous malformed vessels in the posterior temporal lobe successfully treated with CyberKnife and its treatment effects on imaging around 5,10, 18 and 30 months afterwards.
The contrast uptake visible 10 and 18 months after stereotactic radiosurgery seems to be due to a tissue reaction with edema, inflammation and increased permeability, which can be commonly found after a certain amount of time 1,2.