Multiple Arterial Feeders Research Articles

Endovascular and percutaneous embolization of a giant post traumatic arteriovenous fistula of inferior epigastric vessels

BackgroundArteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of time. They tend to recruit multiple arterial feeders with remodelling in the feeding arteries, making them challenging to treat.Case presentationWe discuss a rare case of a 60-year-old male who presented with complaints of a progressive painless swelling in right lower abdomen. There was a history of blunt injury to abdomen at the same site during alleged road traffic accident 3 years ago. On CT angiography, an arteriovenous fistula was localised to the anterior abdominal wall arising predominantly from the right inferior epigastric artery with a giant venous sac and terminating as a tortuous single venous channel into the right external iliac vein. Few other small feeders were also seen arising from branches of right superior epigastric artery along Winslow’s pathway. The main challenge in endovascular management of this patient was embolization of a high flow shunt with a large venous sac and multiple arterial feeders. The dominant arterial feeder was embolized using vascular plug. The superficial location of the lesion offered an additional percutaneous window besides endovascular approach. The venous sac was percutaneously accessed and embolized using n-butyl cyanoacrylate after balloon occlusion of outflow vein. On follow up ultrasonographic evaluation at 3 months, near complete thrombosis of the venous sac was achieved.ConclusionsTraumatic arteriovenous fistulas involving the inferior epigastric vessels are rare clinical entities. CT angiogram and digital subtraction angiography help in the optimal diagnosis and treatment planning. The use of mechanical embolization devices to cause flow arrest offers an opportunity to use liquid embolic agents which offer better percolation within the lesion. Interventional radiology offers an ideal management of these complex high flow fistulas with a good technical success and acceptable safety profile.

Vein of Galen malformations in the newborn: case series.

Vein of Galen malformations (VoGMs) in newborns often represent life-threatening emergencies. Outcome is difficult to predict. The authors review 50 VoGM cases to correlate anatomical types with treatment and outcome. Four distinct types of VoGMs are identified: mural simple (type I), mural complex (type II), choroidal (type III), and choroidal with deep venous drainage (type IV). Seven patients presented with mural simple VoGMs with a "single hole" fistula supplied by only one large feeder. These patients were treated electively at >6 months; development was normal. Fifteen patients presented with complex mural VoGMs. Multiple large feeders joined a single fistulous point within the wall of the varix. Patients typically presented with congestive heart failure (CHF) and required emergent transarterial intervention. Mortality was 7.7% with less than two-thirds developing normally. Twenty-five patients presented with choroidal VoGMs. Multiple large arterial feeders joined at multiple fistulous sites. Severe CHF in most patients required emergent transarterial and sometimes transvenous intervention. Mortality was 9.5%; two-thirds of the patients had a normal development. Three babies presented with choroidal VoGMs with deep intraventricular venous drainage. This phenomenon caused fatal "melting brain syndrome" in all three patients. Recognition of the specific VoGM type determines treatment options and sets outcome expectations.

Vertebral-Venous fistulas: Single center experience and practical treatment approach

Vertebral-venous fistulas (VVFs) are rare. Scarce literature exists to guide our understanding and management. We report our experience and propose a classification based on flow, feeder number, and involvement of accessible veins. Additionally, we include a practical treatment approach. Retrospective chart and imaging review of cerebrovascular arteriovenous fistulas treated in our center between July 2013 and April 2022. We reviewed patient demographics, presentation, imaging, treatment strategies, and outcomes. Nine patients with VVFs were identified, six were females. Ages ranged between 38-83 years. There were six high-flow and three low-flow. Most VVFs originated at the level of V3. Additional feeders from the internal carotid artery, external carotid artery, and/or subclavian artery were present in four cases (two were high-flow). Four cases had multiple arterial feeders. All cases were symptomatic. Origin was spontaneous in eight and iatrogenic in one case. Most common presenting symptoms were pain (7) and pulsatile tinnitus (4). Neurological deficits were present in two cases (1 high- and 1 low-flow). Four cases were treated with vertebral artery segmental sacrifice alone, three required multiple transarterial embolizations with or without VA sacrifice, one case had single transvenous approach, and one was treated with single targeted transarterial embolization. One patient had a minor transient neurological complication. No treatment-related mortality was seen. Treatment of high-flow and symptomatic low-flow VVFs is feasible and safe. Our classification and treatment approach might help guide patient selection and choice of endovascular approach. However, our approach warrants further validation with a larger number of patients.

A Study of Arterial Supply to Carotid Body Tumor and Its Prospective Implication in Clinical Practice

Introduction and Objectives: Arterial supply to carotid body tumor is primarily from ascending pharyngeal artery (APA), a branch of the external carotid artery, and with infrequent feeders from other branches of the latter described in the literature. The present study attempted in describing other sources of arterial supply to carotid body tumor and its implication in clinical practice. Materials and Methods: This study was retrospective to start with turning a prospective midway for 5 years from July 2017 to July 2022. The data of all the 12 patients, in whom seven males and five females with a mean average of 45 years, were analyzed, There were seven males and five females with the mean age of 45 years; the average size of the tumor documented was 5 cm. All the patients underwent computed tomography angiography for confirming the diagnosis. Three-dimensional volume-rendered images from the rotational angiogram were analyzed for assessing the arterial supply. All patients underwent surgical excision without embolization. Results: In all 12 patients, APA was found primarily the main source of blood supply. Four patients, in addition, had occipital artery and superior thyroid in one. Two patients were identified to have glomic artery arising from the bulb of the common carotid artery supplying the tumor. The thyrocervical trunk was also supplying the tumor in a patient. Anomalous branches from the internal carotid artery were found to be the sole source of arterial supply to the tumor in a patient. Conclusion: Surgical excision of carotid body tumors still continues to be a challenge due to multiple arterial feeders leading to hypervascularity. A detailed knowledge of arterial supply helps in proper planning and reducing perioperative bleeding. The glomic artery, and in rare cases, the internal carotid artery, also contribute as a feeder to the tumor. These unusual arterial feeders give an important warning before routine embolization to avoid cerebrovascular events.

909: MULTIPLE ARTERIAL COLLATERALS TO AN ASPERGILLOMA CAUSING RECURRENT HEMOPTYSIS

Introduction: Aspergillus is a fungus that is ubiquitous in the environment and causes various clinical syndromes depending on host characteristics. The spectrum of disease affects 3 million people worldwide and ranges from an asymptomatic fungal ball to lung destruction. We present a patient with a history of tuberculosis and pulmonary aspergilloma which parasitized multiple arterial sources including the bronchial artery, internal mammary artery, and several subclavian artery branches with venous fistulization. Description: A 79-year-old man presented with 6 months of daily hemoptysis. His past medical history was significant for diabetes mellitus, severe centrilobular emphysema, mycobacterium avium complex infection, and previously treated tuberculosis. A computed tomography scan of the chest demonstrated a left upper lobe (LUL) mass with cavitation. He underwent flexible bronchoscopy with bronchoalveolar lavage and endobronchial biopsy of the LUL. The fungal culture grew Aspergillus fumigatus which correlated with the biopsy which revealed a conglomerate of septate hyphae consistent with an aspergilloma. He was referred for bronchial artery angiogram with embolization. During the procedure multiple arterial feeders to the aspergilloma were identified. This included the left bronchial artery, left internal mammary artery, left superior thoracic artery, left thoraco-acromial artery and left lateral thoracic artery. Each of these arteries supplying the aspergilloma demonstrated the added complexity of venous fistulization. Due to the presence of venous fistulas, embolization was performed using n-butyl cyanoacrylate with lipiodol. Considering the patient’s clinical stability, length of procedure and radiation time and contrast administered, as well as the absence of active bleeding during the procedure, the left internal mammary artery and left thoraco-acromial artery were not embolized with the intent of a follow-up procedure. Discussion: Chronic pulmonary aspergillosis can cause life-threatening hemoptysis when arterial feeders develop to supply an aspergilloma. First line treatment options include bronchial arterial embolization. This case highlights the unusual presentation of an aspergilloma that both parasitized numerous systemic arteries while forming venous fistulas, a rare phenomenon.

Technique to "Trap" a Segment of the Middle Meningeal Artery for Embolization of a Carotid Cavernous Fistula: 2-Dimensional Operative Video.

Transvenous embolization is the favored treatment for indirect carotid-cavernous fistulas (CCFs). However, transarterial embolization can be used as an alternative method when the venous route is inaccessible. We present the case of a 47-yr-old woman with a history of diplopia, headaches, and sixth cranial nerve (CN-VI) palsy who presented with acute worsening of headache and ophthalmoplegia and rise of intraocular pressures. Angiography demonstrated a left indirect CCF (dural arteriovenous malformation) with multiple arterial feeders from the internal carotid artery as well as the middle meningeal artery (MMA) (Barrow type D). Transvenous approach was attempted first but was unsuccessful due to difficult access to the cavernous sinus. Thus, transarterial embolization through the MMA feeding branches was planned. To avoid occluding distal branches of the MMA by Onyx, we coiled it distally. In addition, we used a scepter balloon proximally to prevent the reflux of Onyx into potential collaterals to cranial nerves from proximal MMA. After trapping a segment of the MMA, Onyx was injected into the CCF fistula through the small MMA feeders. A postembolization arteriogram showed obliteration of the CCF. The patient developed mild left facial nerve paresis on the first postoperative day (thought to be related to partial embolization of tiny arteries in the facial canal), which was resolving in the course of hospitalization. She remained neurologically stable, and was discharged on the third postoperative day. To the best of our knowledge, this is the first report of transarterial embolization of CCF by distal coiling and proximal ballooning to trap a segment of an artery. The authors hereby confirm that informed consent was obtained from the patient after thorough discussion of the procedure's rationale, risks, benefits, and alternatives.

Clinical Characteristics, Angioarchitecture and Management of Tectum Mesencephali Arteriovenous Malformations : ARetrospective Case Series.

Tectum mesencephali arteriovenous malformations (TM-AVMs) are rare lesions deeply located close to eloquent structures making them challenging to treat. We aimed to present clinical presentation, angiographic features and treatment strategies of TM-AVMs through asingle center retrospective case series. A TM-AVMs is defined as anidus located in the parenchyma or on the pia mater of the posterior midbrain. Records of consecutive patients admitted with TM-AVMs over a21-year period were retrospectively analyzed. Vascular anatomy of the region is also reviewed. In this study 13 patients (1.63% of the complete cohort; 10males), mean age 48years, were included. All patients presented with intracranial hemorrhage and two patients (15%) died after an early recurrent bleeding. Mean size of the TM-AVMs was 10.1 ± 5 mm. Multiple arterial feeders were noted in every cases. Of the patients 11 underwent an exclusion treatment, 8via embolization (6via arterial access and 2via venous access) and 4via stereotactic radiosurgery (SRS) (1patient received both). Overall success treatment rate was 7/11 patients (64% overall; 63% in the embolization group, 25% in the SRS group). Two hemorrhagic events led to aworsened outcome, one during embolization and one several years after SRS. All other patients remained clinically stable or improved. The TM-AVMs are rare but stereotypic lesions found in ahemorrhagic context. Multiple arterial feeders are always present. Endovascular treatment seems to be an effective technique with relatively low morbidity; SRS had alow success rate but was only use in alimited number of patients.

Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes

IntroductionCranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes. MethodsTwenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months. ResultsFour patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5. ConclusionsComplex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.

Cerebral Proliferative Angiopathy: An Uncommon and Misdiagnosed Entity

AbstractCerebral proliferative angiopathy (CPA), previously known as diffuse nidus-type arteriovenous malformation (AVM) is an entity distinct from cerebral AVM, characterized by multiple small arterial feeders, large-size nidus involving entire lobe or hemisphere, and no early draining veins with normal brain parenchyma interspersed between the abnormal vessels. It is usually seen in younger age group and is more common in females. We hereby report a case of diffuse cerebral proliferative angiopathy in a 29-year-old man who presented with intracranial hemorrhage. It is important to recognize this entity to avoid aggressive treatment, thus preventing permanent damage to the normal intermingled brain tissue.

Why Does Large Venous Pouch Thrombose after Cerebral Arteriovenous Shunts Embolization?

Why Does Large Venous Pouch Thrombose after Cerebral Arteriovenous Shunts Embolization?

An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus.

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS. A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS. The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

The rare case of a large complex intraosseous cranial arteriovenous malformation with successful multidisciplinary management

Intraosseous cranial arteriovenous malformations (AVMs) are very rare, challenging entities. The authors report the case of an extracranial parietooccipital vascular lesion. A 12-year-old boy presented with accelerated growth of a right scalp lesion over a few months. Digital subtraction angiography showed a large, right parietooccipital intraosseous AVM with multiple complex arterial feeders. Treatment of these lesions is difficult and can necessitate a multidisciplinary approach. In the featured case, 6 embolization procedures were performed over 1 year, including both transarterial and transvenous approaches, followed by total resection. The authors describe what is thought to be the second case of an AVM originating in the cranial bones and the first case with successful multidisciplinary management.

Gamma Knife surgery for clival epidural-osseous dural arteriovenous fistulas.

OBJECTIVE Clival epidural-osseous dural arteriovenous fistula (DAVF) is often associated with a large nidus, multiple arterial feeders, and complex venous drainage. In this study the authors report the outcomes of clival epidural-osseous DAVFs treated using Gamma Knife surgery (GKS). METHODS Thirteen patients with 13 clival epidural-osseous DAVFs were treated with GKS at the authors' institution between 1993 and 2015. Patient age at the time of GKS ranged from 38 to 76 years (median 55 years). Eight DAVFs were classified as Cognard Type I, 4 as Type IIa, and 1 as Type IIa+b. The median treatment volume was 17.6 cm3 (range 6.2-40.3 cm3). The median prescribed margin dose was 16.5 Gy (range 15-18 Gy). Clinical and radiological follow-ups were performed at 6-month intervals. Patient outcomes after GKS were categorized as 1) complete improvement, 2) partial improvement, 3) stationary, and 4) progression. RESULTS All 13 patients demonstrated symptomatic improvement, and on catheter angiography 12 of the 13 patients had complete obliteration and 1 patient had partial obliteration. The median follow-up period was 26 months (range 14-186 months). The median latency period from GKS to obliteration was 21 months (range 8-186 months). There was no intracranial hemorrhage during the follow-up period, and no deaths occurred. Two adverse events were observed following treatment, and 2 patients required repeat GKS treatment with eventual complete obliteration. CONCLUSIONS Gamma Knife surgery offers a safe and effective primary or adjuvant treatment modality for complex clival epidural-osseous DAVFs. All patients in this case series demonstrated symptomatic improvement, and almost all patients attained complete obliteration.

Intracranial Pial Arteriovenous Fistulae: Diagnosis and Treatment Techniques in Pediatric Patients with Review of Literature.

Pial arteriovenous fistulae (AVF) are rare vascular lesions comprising single or multiple arterial feeders draining directly into the venous channel without intervening tangle of blood vessels as in brain AV malformations. In our present paper, we describe three cases of pial AVF in the pediatric age group with different presentations treated successfully with endovascular and surgical methods. Two patients underwent treatment for pial AVF by the endovascular technique and one by surgical clipping. The treatments were successful with good clinical outcome. We did not encounter any peri-procedural complications in any of the cases. Pial AVF is a rare entity and high degree of suspicion and adequate clinical and imaging knowledge is required to make the diagnosis. Exclusion of the fistula from the cerebral circulation should be done at the earliest to prevent devastating complications that result during the natural course of the disease.

Fetal MRI demonstrating vein of Galen malformations in two successive pregnancies--a previously unreported occurrence.

Vein of Galen malformations are rare and are usually detected in utero using ultrasonography. No definite genetic predisposition has been described in the literature. We present a case with two successive pregnancies complicated by vein of Galen malformations, which were assessed using fetal MRI. The putative role of genetic mutations is also discussed. A 30-year-old primigravida presented in the third trimester with a fetus diagnosed with vein of Galen malformation on sonography. MRI and MR angiography were performed for further assessment. The subsequent pregnancy was again complicated by vein of Galen malformation. In addition to MRI, genetic analysis was carried out on both fetuses and on the parents. MR angiography revealed that both fetuses suffered from the choroidal sub-type of vein of Galen malformation, with multiple arterial feeders fistulating onto a midline venous pouch. The visualised anatomy obtained was far superior than on sonography and allowed categorisation of vein of Galen malformation sub-type. Genetic analysis on the mother and both fetuses showed variant RASA1 gene mutation. This case demonstrates that fetal MRI is a powerful tool in the investigation of in utero neurovascular malformations. A genetic mutation was identified, but this was of uncertain significance.

Dural arteriovenous fistulas of the cavernous sinus - clinical case and treatment

Abstract The purpose of our article is to present the results of our treatment of dural arteriovenous fistula of the cavernous sinus by glue embolization of the external carotid artery feeders. By this case presentation we try to clarify the clinical course, with the dural carotid cavernous fistula (CCF), characterizing a pallet of symptoms, paying special attention to radiological finding and endovascular treatment. Dural arteriovenous fistulas represent 10% to 15% of all intracranial arteriovenous malformations (A. Fox, G. Duckwiler, “Dural Arteriovenous Fistula,” presented at the annual meeting of the American Society of Neuroradiology, St Louis, Mo, June 1992). Dural arteriovenous fistulas are rare clinical situation, especially examples involving the cavernous sinus. Most dural fistulas are acquired conditions, typically occurring in postmenopausal women, but sometimes in other patients in association with other condition [1,3]. These dural fistulas are most often “spontaneous” cavernous carotid shunts (usually low-flow) [2, 4, 5], usually related to a past trauma or surgery. The classical triad, represented by pulsating exophthalmos, conjunctival chemosis, and pulsatile-tinnitus are well-known clinical symptoms of these lesions but are not necessary present in the majority of the patients as first indicators. The anatomy of these vascular malformations consists of multiple arterial feeders flowing into cavernous sinus. The arterial feeders are usually meningeal branches arising from the internal carotid artery (ICA) or the external carotid artery (ECA). However, there are few reports of large series [1], and the clinical entity is not widely known. The purpose of this paper is to present a clinical case of a patient with dural cavernous sinus fistulae, clarify the clinical symptoms course and special attention to results of endovascular treatment.

Time resolved imaging of contrast kinetics (TRICKS) MR angiography of arteriovenous malformations of head and neck

PurposeTo evaluate vasculature of arteriovenous malformations (AVMs) of head and neck with time resolved imaging of contrast kinetics (TRICKS) MR angiography (MRA). Material and methodsProspective study was conducted upon 19 patients (age range, 12–29 years; mean age 18 years; 10 males and 9 females) with AVM of head and neck. TRICKS-MRA of head and neck was performed during injection of contrast medium. Post processing with reconstruction of the images was done. Two independent readers assessed the overall TRICKS-MRA image quality score using a 5-point scale and depiction of the main arterial feeders, nidus, and venous drainage using 3 points scale. The Kappa test for interobserver agreement was done. The AVMs were evaluated morphologically in terms of number and origin of the main arterial feeders, the location and size of nidus either small (>2cm) or large (>2cm) and the draining veins into the superficial or deep venous drainage. ResultsThe average TRICKS-MRA image quality score as judged by reader 1 was 3.89±1.15 and that as judged by reader 2 was 3.89±0.10, which yielded excellent interobserver agreement (k=0.77, 95% CI=0.53–0.98, r=0.78, P=0.001). The interobserver agreement of both readers was excellent for the arterial feeders (k=0.81, 95% CI=0.57–1.00, r=0.83, P=0.001), excellent for the nidus (k=0.91, 95% CI=0.75–1.00, r=0.92, P=0.001), and good for the venous drainage (k=0.77, 95% CI=0.53–0.98, r=0.78, P=0.001). The arterial feeders were single (n=14) or multiple (n=5), the nidus was large (n=16) or small (n=3) and the venous drainage was into the internal jugular (n=17) or the external jugular (n=2) veins. Three patients with small nidus and single arterial feeder were treated with sclerotherapy. Eleven patients with large nidus and single arterial feeder were referred for embolization. Combined embolization and surgery were done for five patients with large nidus and multiple arterial feeders. ConclusionWe concluded that TRICKS-MRA is a reliable non invasive tool for evaluation of the feeding arteries, the nidus and the draining veins of AVMs of head and neck. TRICKS-MRA can be used for evaluation and treatment planning of AVMs of head and neck.

Transvenous to arterial Onyx embolization

Background/objectiveTransarterial infusion of Onyx is now widely used in the treatment of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs). Transvenous Onyx embolization is rarely performed, and usually in cases...

Total resection in a giant left frontal arteriovenous malformation, grade V Spetzler-Martin - Case report

Abstract Background: Giant arteriovenous malformations (AVMs) are congenital lesions, with nidus sizing more than 6 cm. According to Spetzler-Martin scale, grade V AVMs have a nidus larger than 6 cm in diameter, profound venous drainage and are located in eloquent areas. Method: We report a case of a 39 years old woman, with giant left frontal AVM, grade V Spetzler-Martin, who was admitted for generalized seizures, with onset 32 years ago, refractory to full dose antiepileptic polytherapy, which severely impaired the patient’s quality of life. Results: The patient underwent surgery and we performed total resection of the AVM. We emphasize on surgical technique, intraoperative difficulties and outcome. Conclusions: Surgery is the therapy of choice in AVMs, because it provides cure of the lesion, and is the only treatment capable of preventing hemorrhage and controlling seizures. Management in grade V AVMs is challenging, because of their large size, multiple dilated arterial feeders from anterior and posterior circulation and external carotid arteries, high blood flow, vascular steel from the surrounding brain, enlarged draining veins, profound venous drainage and location in eloquent area. Giant AVMs with high flow nidus, causing a great degree of vascular steel in the surrounding brain, with hypoperfusion of normal parenchyma may develop early normal perfusion pressure breakthrough. Total resection in grade V AVMs can be performed with minimal transient morbidity and favorable outcome. Total resection permits control of intractable seizures with reduced dose of antiepileptic therapy.

Pial Arteriovenous Fistula as a Cause of Bilateral Thalamic Hyperintensities—an Unusual Case Report and Review of the Literature

Isolated bilateral thalamic congestion due to an arteriovenous malformation (AVM) is a rare entity. Few case reports of dural arteriovenous fistula associated with it have been reported in the literature. The association of pial arteriovenous fistula (pial AVF) with thalamic hyperintensities has never been described before. The pial AVF is a recently recognized lesion in which the multiple pial arterial feeders drain into a single venous channel without a nidus like in conventional AVM. In spite of being congenital in origin, these lesions may have expression in adulthood due to abrupt change in the venous drainage system. Successful management of pial AVF associated with bilateral thalamic hyperintensities is described here with review of the literature. A 60-year-old man presented with rapidly progressive gait disturbance and cognitive decline. Magnetic resonance imaging (MRI) showed hyperintensities in the thalami on T2-weighted and fluid attenuated inversion recovery image. Digital subtraction angiography revealed a pial AVF near the splenium of corpus callosum. It had feeders from posterior choroidal arteries and drained into the vein of Galen through an abnormal mesencephalic vein. The stagnation and increase of pressure in the deep venous system led to congestion in the thalami. He was treated by partial transarterial embolization of the feeders followed by gamma knife therapy (GKT). The clinical symptoms and MRI improved rapidly after embolization and further reduction in shunt flow was observed after GKT. Strong suspicion of vascular malformation as a cause of bilateral thalamic hyperintensities helps in early detection. Such lesions like pial AVF presented here require active intervention by surgery or endovascular therapy. GKT is an important adjuvant in lesions refractory to either of them.