Presentation
Seizure.
Patient Data
Technique: Volumetric imaging acquisition through the brain has been obtained pre and post-contrast administration, including CT arterial angiogram.
Findings: There is a right superior frontal gyrus arteriovenous malformation characterized by a compact nidus measuring 1,9 cm and being supplied by distal branches from the right ACA and right MCA, and drained by superficial cortical veins that finish at the superior sagittal sinus. There is no signs of acute hemorrhage. The remainder brain parenchyma is unremarkable.
Conclusion: Right frontal arteriovenous malformation (Spetzler-Martin grade 2).
Technique: Multiplanar and multisequence images have been obtained through the brain, including MRA and volumetric axial T1 for stereotaxic purposes.
Comparison: Comparison is made with the previous CT scan.
Findings: The arteriovenous malformation is again demonstrated in the posterior right superior frontal gyrus, with a compact 1.9 cm nidus in the precentral sulcus, in contact with the anterior surface of the right precentral gyrus (eloquent brain area - close to the motor cortex). The signal loss with blooming and the minimal surrounding high T2 signal are stable in appearance. Its arterial supply was previous demonstrated to be from distal branches from the right anterior and middle cerebral arteries. The venous drainage is made by cortical veins to the superior sagittal sinus, a venous varix appears present superficially.
The brain parenchyma is otherwise unremarkable. No abnormal diffusion restriction or acute/subacute hematomas.
The remainder circle of Willis and vertebrobasilar system opacity normally. No evidence of significant arterial stenosis or aneurysm.
Conclusion: Stable appearance of the right frontal arteriovenous malformation (Spetzler-Martin grade 2).
Cerebral angiogram (DSA)
Procedural notes: 5F Right CFA access. Bilateral internal and external carotid / Bilateral vertebral angiograms. Manual hemostasis.
Findings: There is a 1.8 cm AVM nidus within the precentral right frontal lobe. The dominant arterial supply is from an enlarged posterior frontal cortical branch of the anterior cerebral artery, there is additional arterial supply from distal right middle cerebral artery branches. The ACA supply is dysplastic with focal stenosis just before the nidus.
No feeding artery or circle of Willis aneurysms identified.
No external carotid arterial supply.
Venous drainage is superficial, via an enlarged superficial cortical vein to the subjacent superior sagittal sinus. There is no deep venous drainage identified.
Bilateral occipital DVA's are incidentally noted.
Conclusion: Grade 2 right posterior frontal AVM.
Case Discussion
This case illustrates a cerebral arteriovenous malformation with:
- compact nidus located in an eloquent area (adjacent to the right precentral gyrus - motor cortex) - 1 point
- small, measuring less than 3.0 cm - 1 point
- superficial venous drainage - 0 point
Which scores as a grade 2 according to the Spetzler-Martin AVM graduation system.
Note that in these case, both the CT and MRI angiograms were able to spot the vascular malformation with great confidence when compared to the DSA.
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