J Cerebrovasc Endovasc Neurosurg.  2016 Sep;18(3):291-295. 10.7461/jcen.2016.18.3.291.

Onyx Embolization of Intracranial Pial Arteriovenous Fistula

• Kim HM
• Cho JH
• Kim KH

• KMID: 2355657
• DOI: http://doi.org/10.7461/jcen.2016.18.3.291

Abstract

Intracranial pial arteriovenous fistulas (AVFs) are rare cerebrovascular lesions consisting of one or more arterial connections to a single venous channel without an intervening nidus. Because of the location and high flow dynamics of these lesions, neurosurgeons may have a difficulty deciding between endovascular treatment and open surgical treatment. We report on a patient who underwent endovascular treatment with liquid embolic agent. A 50-year-old man with a decreased mental state and a tonic seizure event was brought to our hospital. Computed tomography (CT) of the brain showed a subcortical hematoma in the right temporoparietal lobe. On three-dimensional cerebral artery CT, there was no evidence of definite cerebrovascular abnormality. Cerebral angiography showed a pial AVF supplied by the right middle cerebral artery with early drainage into the right superior cerebral vein. The patient was treated with Onyx embolization for definitive closure of the fistula. The patient was transferred to the department of rehabilitation medicine two weeks later with grade 4 left hemiparesis. The application of advanced equipment, such as the latest angiography and endovascular tools, will facilitate the correct diagnosis and delicate treatment of pial AVF.

Keyword

Intracranial; Onyx; Pial; Arteriovenous fistula

MeSH Terms

Angiography
Arteriovenous Fistula*
Brain
Cerebral Angiography
Cerebral Arteries
Cerebral Veins
Diagnosis
Drainage
Fistula
Hematoma
Humans
Middle Aged
Middle Cerebral Artery
Neurosurgeons
Paresis
Rehabilitation
Seizures

Figure

• 

  Fig. 1 A CT scan on admission showing a subcortical ICH on right temporo-parietal lobe. CT = computed tomography; ICH = intracranial hematoma.

• 

  Fig. 2 (A) Three dimensional reconstruction of the right ICA angiography. A thin arteriovenous fistula is shown (white arrow). (B) A magnified angiography of right ICA, lateral view. (C, D) Super-selective micro-catheter angiography of right distal middle cerebral artery confirms a pial arteriovenous fistula supplied by the distal branch of inferior division of right distal MCA. ACA = anterior cerebral artery; MCA = middle cerebral artery; ICA = internal carotid artery.

• 

  Fig. 3 (A) A magnified angiography of right ICA, lateral view showing disappearance of pial arteriovenous fistula. (B) Three dimensional reconstruction of the right ICA angiography. Onyx material, embolic agent, is shown (white arrow). ICA = internal carotid artery.

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