Presentation
A young female presented with a nicotine overdose and weakness of right leg and arm.
Patient Data
Large left intraparenchymal hematoma centered at the level of basal ganglia extending intraventricularly, with mild rightward midline shift and signs of secondary ventricular sequestration of ventricles bilaterally.
Left-sided arteriovenous malformation is seen just lateral to the parenchymal hematoma. Arterial supply arising ipsilaterally from the MCA (M2 segment) with superficial and deep venous drainage; consistent with grade 3-4 AVM (Spetzler-Martin grading system).
The hemorrhage is possible to be directly caused by the AVM, or related to a hypertensive state in the context of damage and gliosis of the surrounding tissue thought to be triggered by a chronic vascular disruption that led to a vascular steal phenomenon.
Right internal carotid artery: from the left A2 segment, a tortuous pericallosal branch is visualized feeding the nidus in the insular area; drainage is seen through an ectatic superficial Sylvian vein draining into the transverse sinus.
Left internal carotid artery: demonstration of a large AVM. The feeding arteries are seen from the lenticulostriate branches to the inferior component, and from the enlarged superior division branches of the MCA to the rest of the AVM. There is rapid venous shunting to a superficial middle cerebral vein, and eventually to the vein of Labbe and the transverse sinus. There is no definite evidence of draining to the internal venous system.
Successful embolization of the medial part, supplied from ACA branches, of the left insular AVM nidus was achieved.
Case Discussion
A successful, partial, embolization of a large AVM presenting with hemiplegia in context of nicotine overdose was achieved in this case. There was no complication, or expansion of the hematoma with supportive management and blood pressure control. Furthermore, the patient was sent for radio-surgical management.
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