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A 22-year-old suffering from sudden right hemiplegia and mutism received emergency stroke treatment after an MRI confirmed a large deep hematoma – an AVM in the white matter with single venous drainage in the deep venous system. At 8-month follow-up, after the patient recovered with no aphasia or cognitive impairment, the decision is taken to embolize the culprit aneurysm.
With commentary by Prof. Jacques Moret, join Prof. Laurent Spelle, assisted by Drs. Jildaz Caroff (Paris) and Igor Pagiola (Brazil), as they perform this live case from LINNC Paris 2019. Underlining the differences between an arterial and venous approach, the specific challenges of the venous approach are explored including the complexity of correctly visualizing and understanding the anatomy involved. The critical role played by the use of double injections through the artery and veins to avoid superimposition between the normal anatomy and the venous drainage of the malformation are described. As the case unfolds, Prof. Moret comments on the problems encountered: the difficulty in visualizing many veins; the fact that their modification during an intervention could be more pronounced than an artery; the frequent challenge of ensuring you are not navigating outside the track of the target vein into one of the tributaries veins. We follow the reasoning involved in the choice of embolic material – SQUID 18LD and SQUID 12 (glue 50% ready to use) – and, how it’s use depends on the hemodynamics observed inside the vein or the fact that, as it is not possible to place 2 catheters and block the flow, a “plug and push technique” or “sandwich technique” using the two different densities of the embolic material is employed.
Questions arise as to whether radiosurgery is an option or why the decision was taken initially to first treat the source of the bleeding, and then wait for the patient to recover before approaching the malformation… all this, and more in a very complex intervention here…