Temporal AVM embolization via double access

Patient presentation

• 67 Y/O woman
• PMH: Breast CA
• Syncope
• MRI to investigate for metastases
• Flow voids in the right temporal pole with encephalomalacia

Arterial feeders

• Mainly from temporopolar branch and anterior temporal artery

Venous drainage

• Laterally: superficial frontal cortical vein then SSS
• Medially: medial aspect of the sphenoparietal sinus then cavernous sinus

AVM

• Rt Temporal pole AVM
• Spetzler-Martin 2
• Large venous aneurysm

Treatment options

• Observation:
  • Dangerous features
  • ARUBA TRIAL
  • TOBAS registry
• Surgical resection
  • Close proximity to MCA
  • Diffuse nature of the AVM
• Radiation
  • Dangerous features
  • Diffuse AVM
• Embolization:
  • Non-eloquent location
  • Double approach with intent to cure

Microcatheters simultaneous injection

Venous access

• Right IJ: avoid catheter stretching in heart
• 4 Fr vert catheter
• Apollo (3 cm) allow reflux

Arterial access

• Distal: Apollo 1.5 cm
• Proximal: Marathon
• Aid with control during embolization

Venous injection after arterial embolization showing AVM remnant

1-year follow-up