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Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM

 

This 48 year old female has a history of several epileptic seizures in adolescence. She presented with progressive headache and right leg weakness.
At cerebral MRI a left frontal lesion was detected suggesting vascular malformation with signs of previous intracerebral hemorrhage. As an incidental finding, multifocal white matter disease was noted, consistent with multiple sclerosis. The diagnosis of an AVM was confirmed by both MR and conventional catheter based angiography.
Treatment consisted of endovascular embolization, resulting in partial occlusion, followed by radiation therapy. The patient subsequently developed a mild paresis of the left leg, presumably related to her demyelinating disease.

Left frontal AVM
Examination 1
Fig.1 DSA images (lateral views) after selective injection of the left internal carotid artery demonstrating the frontal AVM. The arterial feeders arise from the anterior cerebral artery but also from the middle cerebral artery (arrows). The lesion is drained towards the superior sagittal sinus, resulting in its early opacification.
Fig.2 DSA images (A-P views) after selective injection of the left (above) and right (below) internal carotid arteries.

Examination 2 (0.5 T)
Fig.3 Sagittal T1-weighted spin-echo images. A large frontal low signal intensity lesion is detected with serpiginous signal void structures within it.
Fig.4 Transverse proton density weighted fast spin-echo images. A triangular shaped area exhibiting a honeycomb appearance is seen in the left frontal region. This image is suggestive of a cortical-subcortical AVM. The nidus is surrounded by a high signal intensity halo, reflecting associated parenchymal lesions. Moreover, other small high signal intensity areas are seen in the periventricular white matter, consistent with multifocal demyelinating disease (multiple sclerosis).
Fig.5 Transverse T2-weighted fast spin-echo images. An oval shaped liquid filled cavity is depicted adjacent to the nidus (arrows on the upper left image), suggesting a previous intraparenchymal hematoma. Otherwise same observations as on Fig.4.
Fig.6 Sagittal averaged modulus (left) and magnitude of complex differences (right) type source images from a Gadolinium-enhanced 3D PC MRA acquisition. The vascular components (nidus) within the abnormal signal intensity area are clearly identified on the magnitude of complex differences type images. The high quality anatomical images reveal that nidus extends from the cortex to the frontal horn of the lateral ventricle.
Fig.7 Sagittal survey 2D PC MR angiogram (Venc: 45 cm/s). This rapidly acquired image (Tac: 36 sec) confirms the diagnosis of the frontal AVM.
Fig.8 Sagittal collapsed MIP reconstruction from a Gadolinium-enhanced 3D PC MRA acquisition (Venc: 45 cm/s) data set and a DSA image (lateral view) after selective injection of the left internal carotid artery, for comparison. The middle cerebral artery feeder to the lesion, although evident on the DSA image, is not well appreciated on the MR angiogram.
Fig.9 Sagittal targeted MIP reconstructions from the Gadolinium-enhanced 3D PC MRA acquisition data set. Dividing the original acquisition volume into two equal sagittal reconstruction subvolumes allows the individual identification of the feeders arising from the anterior cerebral artery (left) and from the middle cerebral artery (right) without confusing vascular superimpositions. This angiotomographic architectural analysis of the AVM during postprocessing is possible only if the geometric characteristics of the lesion are favorable.
Fig.10 Transverse averaged modulus (left) and magnitude of complex differences (right) type source images from a second Gadolinium-enhanced 3D PC MRA acquisition. The triangular shaped nidus and the adjacent post-hemorrhagic frontal intracerebral cavity are well demonstrated.
Fig.11 Transverse collapsed (left) and targeted (right) MIP reconstructions from the second Gadolinium-enhanced 3D PC MRA acquisition data set. The arterial feeders from the anterior cerebral artery (yellow arrows) and the middle cerebral artery (red arrows), the nidus and the draining vein (blue arrow) are clearly visualized in this projection.

 

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Fig. 1

Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 1
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 2
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 3
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 4
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 5
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 6
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 7
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 8
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 9
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 10
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 11
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 12
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 13
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 14
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 15
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 16
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 17
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 18
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 19
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 20
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 21
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 22
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 23
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 24
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 25
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 26
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 27
Pre- and postembolization imaging evaluation of a left frontal cortical-ventricular AVM, Fig. 28