Use of balloon occlusion and substances to protect ischemic brain during resection of posterior fossa AVM. Case report

The successful resection of a large posterior fossa arteriovenous malformation (AVM) is reported. A balloon catheter was used for temporary intraoperative occlusion of the basilar artery and feeding vessels of the AVM. Prior to occlusion of these arteries, newly tested substances to protect the ischemic brain were administered to prolong occlusion time. Resection of the AVM was completed without complication, and the patient returned to normal life. This is a useful intraoperative procedure for the resection of AVM's considered inoperable by conventional approaches.     

A case of hemorrhagic non traumatic arteriovenous fistula of the scalp]

Arteriovenous malformation of the scalp in an uncommon disease and treatment for this lesion is difficult and controversial. A twenty-three-year-old male, who reported no history of head trauma, presented with spontaneous hemorrhage from the left temporal scalp. Neurologically he was normal except the tinnitus. Left external carotid angiography demonstrated arteriovenous malformation fed by the superior temporal and posterior auricular arteries. A dilated tortuous occipital artery was also recognized. The lesions were able to be surgically resected, alleviating intraoperative massive hemorrhage by proximal temporary occlusion of the external carotid artery at the left neck. Small feeding arteries from the meningeal artery which were not recognized on preoperative angiography were found at surgery. The arteriovenous fistula was successfully resected without any cosmetic problem.     

Dural arteriovenous malformation in posterior fossa treated with artificial embolization using a liquid silicon rubber, phycon (author's transl)

Many cases of dural arteriovenous malformation have been reported recently. However, the surgical treatment for these diseases has not been established yet. We propose a new method of treatment on this peculiar vascular diseases, that is one of the artificial embolizations; A catheter is inserted into feeding artery, from which liquid silicon rubber, Phycon, is injected. The rubber is hardened in the vascular net-work. It can not pass into drainer because of its viscosity. Therefore the malformation never develope again. We tried this new method on 46-year-old woman, who suffered from subarachnoidal bleeding, tinnitus and headache. The left common carotid and vertebral angiography revealed dural arteriovenous malformation in posterior fossa (Fig. 1); the feeding arteries of which were middle meningeal arteries, occipital artery, and tentorial artery, etc; the drainers were transverse and sigmoid sinuses. We treated for this case with above-mentioned method; The liquid plastic of 1 - 2 ml injected into each of the main feeding arteries, namely two middle meningeal arteries and occipital artery. Postoperative angiograms revealed this technic was convenient and sufficient for the treatment of dural arteriovenous malformations (Fig. 7).     

The Doppler ultrasonic flowmeter as an adjunct to operative management of cerebral arteriovenous malformations.

The Doppler ultrasonic flowmeter has been used to assist in the removal of five intracranial arteriovenous malformations. The instrument is generally available in most institutions, and is simple and easy to use. It provides a means for locating and confirming the boundaries of a malformation, distinguishing feeding arteries from arterialized draining veins, determining whether the artery is going to the malformation or normal brain, and evaluating the completeness of obliteration.     

Spinal arteriovenous malformations in Klippel-Trénaunay-Weber syndrome: case report

A 19-year-old man was admitted with the chief complaint of a sudden onset of thoracic pain and paraplegia. His right lower limb had progressively enlarged since he was 3 months old. Transient paraparesis had occurred recurrently since the age of 3. Physical examination on admission revealed that there were multiple warts on his face, trunk and right extremities. The right lower limb was thicker and longer than the left one, and the temperature was 1 degree C higher in the right side. Neurological examination revealed paraplegia and severe impairment of all sensory modalities below Th4 with bilateral clonus. Radiological examination showed lordosis of the thoracic spines with thinning of the pedicles of Th4 to Th6. Selective spinal angiography showed a juvenile type of arteriovenous malformation involving the cord of Th2 to Th6 with multiple feeding arteries, and a glomus type of the lower thoracic cord with the feeding arteries from Adamkiewicz's artery and the right Th10 intercostal artery. MRI showed the cord enlargement of Th2 to Th6 and within it the nidus was identified. Spinal arteriovenous malformations associated with Klippel-Trénaunay-Weber syndrome were noticed. The patient underwent interruption of the main feeding artery and removal of the dilated vessels located in the dorsum of the thoracic cord. Postoperative course was uneventful with slight improvement of clinical symptoms. Klippel-Trénaunay-Weber syndrome is manifested by a triad of symptoms: 1) hemihypertrophy of the extremities, 2) cutaneous hemangiomas and 3) arteriovenous fistula or varicose veins of the involved limbs. Nineteen cases of Klippel-Trénaunay-Weber syndrome associated with spinal arteriovenous malformation have been reported. The pathogenesis has been suggested to be due to developmental abnormalities.     

Arteriovenous malformation associated with moyamoya disease: Case report

A rare case of arteriovenous malformation associated with moyamoya disease is reported. In this case, an interesting angiographic change was obtained during the follow-up period. The feeding artery from the internal carotid artery gradually disappeared as the moyamoya disease progressed, and a new feeding artery appeared from the external carotid artery.     

Superselective embolization of spinal arteriovenous malformations using the Tracker catheter.

Eighteen patients with spinal arteriovenous malformations had been treated with conventional embolization, surgical removal, feeder ligation, and/or feeder coagulation between February 1985 and March 1990. The lesions included six glomus, four juvenile, three extramedullary, and five dural arteriovenous malformations or fistulas. Embolic therapy was conducted in 14 patients by introducing the tip of a catheter into the segmental arteries and injecting polyvinyl alcohol strips (500-1000 microns) (conventional embolization). Follow-up spinal angiography disclosed recanalization in 10 patients (71.4%) and the appearance of new feeding arteries in five patients (35.7%). We introduced the Tracker vascular access system in April 1990. Eight patients (four glomus, one juvenile, and three dural arteriovenous malformations) were treated with the minicatheter and Ivalon particles (150-350 microns). Five patients showed neurological improvement immediately after treatment. The other three patients had severe paraparesis before treatment and did not show any improvement. One patient with a glomus-type arteriovenous malformation showed transient neurological deterioration just after embolization with the Tracker-10 to occlude a lesion fed by the posterior spinal artery, because the Ivalon particles migrated into the anterior spinal artery via the anterior spinal canal artery. In one patient with a juvenile arteriovenous malformation, the Tracker-18 catheter perforated the radiculomedullary artery originating from the right vertebral artery, and subarachnoid hemorrhage occurred. However, the Tracker-10 could later successfully occlude the arteriovenous malformation. The rates of recanalization and appearance of the new feeding vessels were 4/8 (50.0%) and 2/8 (25%), respectively.     

Transient neurological deficit after therapeutic embolization of the arteries supplying the medial wall of the hemisphere, including the supplementary motor area

A 27-year-old, right-handed woman underwent intraoperative embolization for a left parasagittal arteriovenous malformation as part of a two stage plan that included subsequent surgical resection of the arteriovenous malformation. This report describes the neurological syndrome that developed after the first procedure. The relation of these deficits to localization of function within the supplementary motor area are correlated with recent advances in our understanding of this region.     

脑动静脉畸形出血的危险因素

目的探讨脑动静脉畸形(BAVM)出血的危险因素。方法收集DSA确诊的BAVM患者105例,分析BAVM出血的危险因素。结果单因素分析表明,BAVM破裂出血的危险因素有病灶位置、大小,供血动脉类型、数目,引流静脉类型、数目、形态及是否合并动静脉瘘;多因素Logistic分析发现,病灶位置、大小,供血动脉类型、数目,引流静脉数目及是否合并动静脉瘘是出血的危险因素,而引流静脉扩张可能是保护因素。结论病灶位于幕下或大脑深部、畸形团3cm、单支静脉引流、单纯穿支动脉供血及多支供血动脉、合并动静脉瘘是BAVM出血的危险因素。     

Multiple arterial fenestrations, multiple aneurysms, and an arteriovenous malformation in a patient with subarachnoid hemorrhage

We report the case of a 49-year-old, right-handed man with multiple vascular pathologies, including a fenestrated anterior communicating artery and middle cerebral artery, an aneurysm of the anterior communicating artery, multiple aneurysms of the middle cerebral artery, and an arteriovenous malformation. Diagnoses were made through computed tomography, cerebral angiography, magnetic resonance imaging, and intraoperative dissection. The lesions were managed surgically in stages with satisfactory results. Congenital and hemodynamic factors may have combined to manifest in the anomalies present in this unique case. We believe that no similar combination of vascular pathology has been reported previously.     

Angiographically occult high cervical dural arteriovenous malformation secondary to intracranial hypertension: a case report

We have recently encountered a case of high cervical arteriovenous malformation which caused subarachnoid hemorrhage. A 54-year-old male was admitted to our hospital due to sudden onset of severe headache. Neurological examination revealed right sixth nerve palsy which suggested elevated intracranial pressure. A CT scan showed subarachnoid hemorrhage predominantly in the posterior fossa, massively ventral to the brain stem, with reflux into the fourth ventricle. No abnormal vascular lesions were found in the first cerebral angiography which included four vessels and bilateral thyrocervical trunks. Ten days later, the second cerebral angiography demonstrated an arteriovenous shunt via the right vertebral artery draining into the epidural space of the upper cervical region. A suboccipital craniotomy and laminectomy of the atlas were performed. An abnormally dilated vein along the right C1 nerve ventral root which drained into the tortuous dilated coronary venous plexus on the ventral side of the spinal cord was found. We made a diagnosis of dural arteriovenous malformation fed by the C1/C2 radicular artery via the right vertebral artery and draining into the radiculomedullary vein and the epidural venous plexus. The interruption of both intra- and extradural draining veins was carried out. The postoperative course was uneventful.     

Hemifacial spasm caused by CP angle AVM associated with ruptured aneurysm in the feeding artery--case report.

A 66-year-old male presented with clinical features of hemifacial spasm. Cerebral angiograms disclosed an arteriovenous malformation (AVM) in the cerebellopontine angle. The hemifacial spasm was caused by a dilated feeding artery of the AVM compressing the facial nerve at the root exit zone. Surgery was not initially performed because of his age and absence of AVM rupture. However, the AVM was associated with a small aneurysm in the feeding artery, which rapidly grew during 20 days after discharge and ruptured causing subarachnoid hemorrhage. The aneurysm was clipped and the feeding artery of the AVM partially obliterated. Careful angiographic examination for associated aneurysms and consequent surgical obliteration to prevent hemorrhage are suggested in cases of AVM.     

Monitoring of cortical blood flow during excision of arteriovenous malformation by thermal diffusion method

The cortical blood flow adjacent to arteriovenous malformations was monitored in six patients before, during, and after excision of arteriovenous malformations using a thermal diffusion probe. In a large arteriovenous malformation, a progressive increase in cortical blood flow up to two times the preexcision value was noted with occlusion of the feeding arteries. Lowering arterial pressure to keep normal cortical blood flow during and after operation resulted in minimum brain edema and an excellent result. Direct measurement of cortical blood flow is of value in determining the precise level of hypotension to prevent brain edema and ischemia that may occur with excision of a large arteriovenous malformation.     

Pulmonary arteriovenous malformation with systemic blood supply]

A forty-eight year-old woman who had suffered from exertional dyspnea and cyanosis since her youth was found to have abnormal shadow in her right lower lung at the roentgenographic examination. Pulmonary angiography showed cavernous network between pulmonary artery and vein of the 8th, 9th, and 10th segments. Bronchial artery was dilated, supplying the cavernous lesion. From these findings this lesion was diagnosed as pulmonary arteriovenous malformation feeded by bronchial artery. Right lower lobectomy was performed. The effect of resection was confirmed by intraoperative arterial gas analysis before and after the excision. She has been doing well without any signs of recurrence for 3 years after the surgery.     

Enlargement of cerebellar arteriovenous malformation associated with fenestration of the vertebral artery--case report.

We report a 30-year-old male case of an enlarged cerebellar arteriovenous malformation (AVM) associated with fenestration of the vertebral artery. Hemodynamic stress resulting from fenestration of the feeding system of AVM was probably an important factor in the enlargement of the small cerebellar AVM.     

Intraoperative magnetic resonance imaging in the successful surgical treatment of an arteriovenous malformation--case report

A 44-year-old female presented with left occipital arteriovenous malformation (AVM) manifesting as sudden onset of severe headache. Magnetic resonance (MR) imaging and conventional angiography showed the left occipital AVM with hemorrhage. Intraoperative MR imaging (iMR imaging) and intraoperative time-resolved imaging of contrast-kinetics (iTRICKS) at 1.5 T revealed complete removal of the nidus of the AVM without conventional catheter angiography. Conventional catheter angiography is commonly used in preoperative and intraoperative examination of AVMs, and for documentation of the surgical outcome, but less-invasive techniques are desirable for both preoperative screening and intraoperative examination. iMR imaging with iTRICKS is less invasive and safer than conventional angiography for both brain tumor surgery and AVM surgery.     

Surgical management of a high-flow arteriovenous malformation of the upper extremity producing severe hemodynamic impairment

Peripheral arteriovenous (AV) malformations may present with a plethora of clinical symptoms such as paradoxical emboli, severe hypertension, nerve palsies or pain syndromes. Hemodynamically compromising lesions of the limbs are rare and involve high-flow AV fistulae with marked arteriovenous shunting. A female patient with a high-flow arteriovenous malformation of the left upper-extremity is presented. Preoperative assessment by magnetic resonance imaging and magnetic resonance angiography together with a color duplex investigation revealed a hemodynamically compromising arteriovenous fistula (shunt volume 30%) involving the entire left forearm and hand. The lesion was managed operatively with a combination of selective ligation and sclerosing of the feeding artery. There was marked clinical improvement postoperatively. Magnetic resonance angiography confirmed a drastic decrease in the number and size of the arteriovenous fistulae. The shunt ratio was diminished to 10%. Although surgical treatment of arteriovenous fistulae is known to have high complication and recurrence rates, thorough preoperative planning and intraoperative monitoring, can supply the prerequisites for a favorable outcome in severe symptomatic cases.     

Impact of ultrasonographic vascular mapping on constructing autogenous arteriovenous fistulas for permanent hemodialysis access?

PURPOSE: We used high resolution ultrasonography to identify usable veins and arteries in the forearm for creation of autogenous arteriovenous fistulas (AVF) for permanent hemodialysis access. The effect of preoperative vascular mapping followed by intraoperative controls on the outcome of AVF should be reported. METHODS: study subjects were adults referred for primary permanent hemodialysis access between January 2001 and November 2002. In all patients sonographic assessment was performed before surgical evaluation. A feeding artery was considered adequate if the diameter was more than 1.5 mm, the vein more than 2.0 mm. All AVF were controlled by intraoperative sonographic measurements of PSV and diameter of the fistula-vein. RESULTS: AVF were placed in 94.1% of all patients. The early failure rate of AVF was 6.3%. Primary patency rate of AVF after 24 hours: 93.7%, after 30 days: 91.4%, after 3 months: 86.9%, preliminary patency rate after 1 year: 70.1%. No unsuccessful surgical explorations were performed. 85.5 % of AVF were constructed as forearm fistulas. Suboptimal vessels (artery < 2.0 mm, vein < 3.0 mm) were used in 31.3% of patients. Patency rates did not differ in this subgroup. In 2 patients synthetic grafts were placed because of non-maturation of AVF. In 15 patients the AVF had to be cannulated by experts for 3 to 6 months. 50.0% of all AVF were constructed in diabetic patients. Patency rates were equal to that of non-diabetic patients. No patient suffered on signs of steal-syndrome. CONCLUSION: the assessment of forearm vessels by high resolution sonographic vascular mapping helps to find the optimal location for constructing an arteriovenous wrist fistula in almost all patients needing a permanent hemodialysis access. The aggressive approach to the creation of autogenous fistulas could be realized without unsuccessful surgical explorations and with a minimal early failure rate, a high maturation rate including patients with diabetes mellitus and no signs of steal-syndrome     

The case against staged operative resection of cerebral arteriovenous malformations

Three cases of large cerebral arteriovenous fistulae are presented in which surgical ablation was complicated by brain swelling from hyperperfusion breakthrough believed to be caused by acute intraoperative hypoperfusion superimposed on chronic preoperative hypoperfusion. On the basis of these cases, experimental data, and theoretical considerations, we seriously question the wisdom of using staged surgical resection of cerebral arteriovenous malformation to prevent complications related to alterations in cerebral hemodynamics. The reasons for this concern are: the repeated occurrence of acute-on-chronic hypoperfusion during staged resection; a lack of understanding of the time course for the correction of a disordered autoregulation; risk of hemorrhage between the initial and final resection; difficulty in assessing and substantiating flow reduction after subtotal resection; the rapidity of collateralization; the divergence of flow from large, readily accessible feeding arteries to deep penetrating vessels; and attenuation of the wall thickness in collateral vessels as a consequence of increased flow.     

Intratesticular Arteriovenous Malformation. Clinical Course, Ultrasound and MRI Findings of an Extremely Rare Lesion on a 7 Year Follow-up Basis

We present the clinical course, sonographic and MRI findings of an intratesticular arteriovenous malformation (AVM) found in a patient during routine check-up for infertility evaluation. Seven years ago, patient’s refusal for surgical removal of the lesion led to follow-up ultrasound examinations and finally to an MRI examination. Arteriovenous malformations of male genitalia have been reported in the literature (penis, scrotum, spermatic cord and epididimys). However, this is the second case of an intratesticular AVM and the first one with a long clinical follow-up.