Endovascular treatment of a pial AVM with large venous pouch in a Covid-19 patient

Clinical background

• 38 Y/M
• Opium addict
• PCR –ve (COVID-19 pneumonia)
• Presented with sudden loss of consciousness with headache and fever, SPO2 85@ 10L. Investigations: LDH 1296, TLC 10.9, platelets 155, Ferritin 131.9. 

Acute phase treatment

• Treated with Solumedrol, Ramdisevir full dose, Anticoagulants 
• Symptomatic treatment

Chest X-ray & HRCT showing COVID pneumonia changes

Brain CT (first day of admission)

brain MRI

Bilateral ICA runs

Venous phase

Left VA run

• Staged arterial embolization
• Start with right ACA feeders, non-aggressive nidal penetration, taking only two feeders per session.
• Don’t want to occlude venous pouch in one go for fear of hemorrhage.

Superselective microcatheter runs

Right arterial femoral access:  

6Fr short sheath, Fargo guiding    

Catheter: Apollo 1.5Fr detachable tip    

Microcatheter: .008 J tip microguidewire

Follow-up MRI / after 6 months

Follow-up DSA – right ICA  (arterial & venous)

Follow-up DSA – Left VA (arterial & venous )

• The patient presented with COVID pneumonia and LOC, GCS 10
• Arterial embolization was performed from the right side using an Apollo microcatheter and onyx, and nidus was obliterated with reduced flow in the large venous pouch.
• The patient’s symptoms immediately improved; the patient was already on antiplatelets due to Covid, so he continued for a while.
• After 6 months, follow-up MRI and DSA were performed, which showed complete obliteration from the right side, however, there was a residual venous pouch filling from the posterior circulation, but the patient was completely symptom-free and back to work, so I decided to wait and monitor with the follow-up strategy (MRI and MRA) every 6 months.