J Korean Neurosurg Soc.  2023 Mar;66(2):199-204. 10.3340/jkns.2022.0165.

Delayed Appearance of Radiologically Occult Cerebral Arteriovenous Malformation : A Case Report and Literature Review

• Park H
• Kang HS
• Cho WS

• KMID: 2539881
• DOI: http://doi.org/10.3340/jkns.2022.0165

Abstract

It is critical to identify the ruptured cerebral arteriovenous malformations (AVMs) for secondary prevention. However, there are rare cases unidentified on the radiological evaluation. We report on a patient with the delayed appearance of radiologically occult AVM as a probable cause of the previous intracerebral hemorrhage (ICH). An 18-year-old male patient presented with a right temporal ICH. The preoperative radiological examination did not reveal any causative lesions. Because of the intraoperative findings suggesting an AVM, however, only hematoma was evacuated. Disappointedly, there were no abnormal findings on postoperative and follow-up radiographic examinations. Eleven years later, the patient presented with an epileptic seizure, and an AVM was identified in the right temporal lobe where ICH had occurred before. The patient underwent partial glue embolization followed by total surgical resection of the AVM and anterior temporal lobe. Based on the literature review published in the era of magnetic resonance imaging, common clinical presentation of radiologically occult AVMs included headache and seizure. Most of them were confirmed by pathologic examination after surgery. In cases of the ICH of unknown etiology in young patients, long-term follow-up should be considered.

Keyword

Intracranial arteriovenous malformation; Occult

Figure

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  Fig. 1. A and B : The initial brain computed tomography and magnetic resonance imaging showed intracerebral hemorrhage in the right temporal lobe with no other causative lesions. C and D : There was no abnormal cerebrovascular lesions on the preoperative digital subtraction angiography (DSA). E : During the surgery, arterialized vein (arrows) were identified. F and G : On the postoperative DSA, there was no clear evidence of abnormal vascular lesion but a suspicious finding of a slow shunt in the right temporal pole (dotted arrow).

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  Fig. 2. A : There were no abnormal findings except cerebromalatic change in the right temporal lobe on the follow-up brain magnetic resonance (MR) imaging in 1 year after hematoma evacuation. B : On the 11-year follow-up MR imaging, multiple signal voids and enlarged vessels were identified in the right temporal lobe. C-E : Arteriovenous malformation (AVM) was found on digital subtraction angiography (DSA), fed by a few branches of the middle cerebral artery and middle meningeal artery. F : Presurgical glue embolization was partially performed through the anterior temporal artery (arrow). G : Intraoperative photo showed embolized anterior temporal artery by the glue (arrow). H and I : Complete removal of the temporal AVM was confirmed on the postoperative DSA.

Reference

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