Safety and Efficacy of Transvenous Embolization of Ruptured Brain Arteriovenous Malformations as a Last Resort: A Prospective Single-Arm Study

A 28-year-old man with intraparenchymal and intraventricular hemorrhage. Ventriculostomy, decompressive craniectomy, and transarterial embolization were performed at the local hospital. Three months later, the selective DSA of the left ICA (anteroposterior [A] and lateral [B] views, both white arrows referring to the nidus) demonstrates that the parietal lobe and basal ganglia arteriovenous malformation are fed by the branches of the MCA and drain a single venous outlet via the deep vein to the straight sinus. The nidus cast was through transvenous embolization (C, unsubtracted image of the DSA), but there is a small residual AVM (anteroposterior [D] and lateral [E] views at the median arterial phase) with drainage via a cortical vein (F, white arrow) to the superior sagittal sinus, which appeared at the late arterial phase of DSA. Thirteen-month angiography follow-up confirms the complete occlusion of the residual AVM (anteroposterior [G] and lateral [H] views at the median arterial phase and lateral view [I] at the late arterial phase).

A 28-year-old man with intraventricular hemorrhage. Selective DSA of the right ICA (anteroposterior [A] and lateral [B] views) demonstrates that the AVM with an intranidal aneurysm (B, white arrow) is fed by perforators of the MCA and ICA and drains a single venous outlet via the deep vein to the straight sinus. Axial MR image indicates a basal ganglia arteriovenous malformation (C, white arrow) with the intranidus aneurysm next to the ventricle (D, white arrow). At the end of the operation, the AVM does not appear at the last angiography (anteroposterior [E] and lateral [F] views), but the cast image shows that the aneurysm does not have complete penetration by the embolic agent (G, white arrow) after transarterial and transvenous embolization. Two days later, intraventricular hemorrhage occurred (H, CT).

An 8-year-old boy who presented with sudden headache and vomiting. CT shows intraventricular hemorrhage. Selective DSA of the left vertebral artery (anteroposterior [A] and lateral [B] views, white arrow) demonstrates that the AVM with an intranidus aneurysm (C, 3D reconstruction, white arrow) is fed by the perforators of the posterior cerebral artery and drains a single venous outlet via the deep vein to the straight sinus. Axial MR image indicates a diencephalon arteriovenous malformation (D, white arrow). Transarterial ethanol sclerotherapy (80% ethanol in iohexol, Omnipaque 300 [GE Healthcare, Piscataway, New Jersey]) was performed to occlude the aneurysm (E, white arrow, the injection course can be seen in the On-line Video). Both the immediate angiography after sclerotherapy and the 2-month follow-up angiography (anteroposterior [F] and lateral [G] views, white arrow) demonstrate occlusion of the aneurysm. At 2-month follow-up, transvenous embolization was performed under transarterial balloon blocking (H). The last angiography (anteroposterior [I] and lateral [J] views) shows complete occlusion of the AVM. The intraprocedure electroencephalography monitoring did not show an abnormality, but the patient presented with light coma or lethargy. The MR imaging performed 12 days after the operation shows multiple infarctions in the mesencephalon (K, white arrow) and thalamus (L, white arrows).