Intraventricular hemorrhage with a high-risk AVM feeder aneurysm

CASE PRESENTATION

A 66-year-old woman with PMHx of HTN, DM2, and remote left cerebellar hemorrhage presented with severe thunderclap headache, vertigo, nausea, and vomiting that started 30 min prior.

IMAGING 

CTH showed extensive subarachnoid hemorrhage in basal cisterns and intraventricular hemorrhage in both lateral, third and fourth ventricles, with associated crowding of the posterior fossa and significant effacement of the fourth ventricle.

INITIAL ANGIOGRAM

ANGIOGRAM

Angiogram showed a small AVM originating from the dural posterior side of the cerebellum with a nidus measuring less than 1 cm with feeders from the right posterior falcine artery and left PICA, with outflow aneurysm originating from the left PICA.

L PICA feeder aneurysm: 3.90 x 3.30 mm; 3.05 mm

MANAGEMENT

The flow aneurysm had evidence of acute rupture with dissecting component and hematoma at the dome of the aneurysm.

MANAGEMENT - STEP 1

The neuro IR treatment was divided into two steps:

•  First, the patient underwent successful embolization of the aneurysm with a WEB device, resulting in its complete occlusion with no associated complication or occlusion of the parent vessel.

WEB device was deployed with successful embolization of aneurysm.

MANAGEMENT - STEP 2

Two days later, the patient underwent another angiogram with the goal of embolizing the AVM feeders.

Accessing the target site.

Embolization of left PICA feeder with Onyx 34 and 18.

Our follow-up run did not show active AV shunting from the L PICA feeder, but we knew penetration through nidus was not enough. Therefore, we predicted another feeder system was still present.

Most of the AVM was still being fed by the left SCA.

Most of the AVM was still being fed by the left SCA.

Onyx 34 then 18 was then used over 30 minutes to penetrate the nidus and occlude the SCA distally.

Post-Onyx embolization, there were still some feeders that we could not safely access, mostly coming from perforating branches of the left SCA.

• Successful embolization of the two feeders of the AVM from the left PICA and left SCA, with persistence of small residual AVM and no complication.
• Four days later the patient underwent open surgical treatment under MRI stereotactic guidance with suboccipital craniotomy for resection of the residual cerebellar AVM. 

POST-OPERATIVE FINDINGS

Post-procedural angiogram three days after open AVM resection showed no residual vascular malformation.

• The patient also underwent right ventriculoperitoneal shunt placement one week later for post-hemorrhagic hydrocephalus.
• Follow-up CT head showed complete clearing of the intraventricular hemorrhages.
• The patient had complete recovery with a non-focal neurological exam on a follow-up appointment one month later.