Cerebral arteriovenous malformation with haemorrhage

Case contributed by A.Prof Frank Gaillard

Presentation

Acute headache.

Patient Data

Age: 45
Gender: Female

Large right frontal intraparenchymal haemorrhage, approximately measuring 6 x 2.5 x 6 cm in perpendicular dimensions; with minimal surrounding vasogenic oedema and mild resultant mass effect effacing the sulci.

Extension of the haemorrhage into the ventricular system noted with blood layering within the dependent position of the lateral ventricles as well as third and forth ventricles. There is perhaps subtle prominence of the temporal horns bilaterally suggestive of an early hydrocephalus.

A right lateral frontal deep white matter arteriovenous malformation, with the nidus measuring approximately 1.5 cm predominantly fed through arteries from the superior branch of the right MCA and perhaps M1 perforators is present; draining via an enlarged deep parenchymal vein into the right internal cerebral vein; prominent rights vein of Rosenthal and Galen.

Associating venous aneurysm/varix is noted, probably protruded into the right lateral ventricle with an impression for possible obstructive effects over the foramen monro on the right side.

No other abnormalities identified.

Conclusions:

Arteriovenous malformation identified, most likely grade III as per Spetzler-Martin classification:

  • Nidus less than 2 cm.
  • Internal cerebral venous drainage.
  • Likely compromising an eloquent area.
DSA (angiography)

Right frontal deep AVM has small nidus from superior division of MCA - small ill-defined, probably from multiple branches (opercular).

Single draining vein passes medially, with venous varix, venous stenosis, then into internal cerebral vein and vein of Galen.

ECA injection showed no supply, and there was none from the contralateral carotid or vertebral injections. No arterial aneurysms identified.

Marked enlargement and retrograde filling of the ophthalmic veins noted on the ECA injection - filling from anterior to posterior - with no evidence of cavernous DAVF.

Conclusion:

Right frontal AVM with haemorrhage, venous stenosis, single draining vein passing to deep venous system. Small nidus, deep drainage, eloquent = Spetzler & Martin grade III.

Case Discussion

Cerebral AVMs are relatively common with a prevalence of ~4%. Haemorrhage is the most common presentation with seizures also common. 

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Case information

rID: 28773
Case created: 11th Apr 2014
Last edited: 11th Oct 2017
Inclusion in quiz mode: Included

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