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Spontaneous Thrombosis of the Main Draining Veins Revealing an Unruptured Brain Arteriovenous Malformation

  • Feng Yan
  • Gao Chen
  • Jianmin ZhangEmail author
Chapter
Part of the Springer Series in Translational Stroke Research book series (SSTSR)

Abstract

A case of AVM was presented and surgical details presented and discussed.

Keywords

AVM Thrombosis Treatment 

1 Case

A 33-year-old man with history of left limbs numbness for 2 years. There was no history of headache and weakness. On examination, patient was fully conscious, cerebellar signs were absent. Magnetic resonance imaging (MRI) with contrast showed an approximately 3.5 cm poorly demarcated mass in the right parietal lobe with significant perilesional edema (Fig. 15.1). Digital subtraction angiography (DSA) revealed a right parietal Arteriovenous Malformation (AVM) with a nidus size of 3.5 cm, supplied mainly by multiple feeders from middle cerebral artery (MCA). Neither pedicle nor intranidal aneurysm was depicted. Cerebral angiography did not show high flow and dilated draining veins. Only small cortical veins draining the AVM slowly into the superior sagittal sinus was seen at the late venous phase (Fig. 15.2). It graded II in the Spetzler and Martin grading scale (nidus: 2 point, eloquence: 0 point, venous drainage: 0 point). Blood test (including Leiden factor, lupus like anticoagulant, homocysteine, anti-CMV abs, anti-EBV abs, anti-HSV abs) were negative. The patient was put on anti-epileptics and he was planned for surgical treatment. Craniotomy was performed and the extracranial soft tissue was coagulated meticulously. After opening the dura, no obvious drainage veins were found on the surface of brain. The AVM was exposed along the edge of the lesion and completely resected. Two large drainage veins were found during this process and no blood flow was observed via Doppler ultrasound (Fig. 15.3). The nidus resection confirmed the hypothesis of a thrombosis of the AVM’s main draining vein. His neurological defects improved after the operation and he was discharged 1 week later.
Fig. 15.1

Brain magnetic resonance imaging (MRI) performed on patient admission. (a) Axial T1-weighted image showing an approximately 3.5 cm poorly demarcated mass in the right parietal lob. (b) Axial T2-weighted image showing severe perilesional edema

Fig. 15.2

Right internal carotid artery digital subtraction angiography (DSA) performed at day two: (a) lateral projections at arterial phase, (b) late venous phase. (c) frontal projections at arterial phase, (d) late venous phase. Nidus is seen in the right parietal lobe (arrows). The arteriovenous malformation (AVM) supplied mainly by multiple feeders from middle cerebral artery (MCA), small cortical veins draining the AVM slowly into the superior sagittal sinus

Fig. 15.3

Intra-operative images showing two thrombosed draining veins (arrow, a, b, c) of the arteriovenous malformation (AVM)

2 Discussion

Spontaneous venous thrombosis in unruptured AVM is rare and only seven cases have previously been published [1, 2, 3, 4, 5, 6, 7]. The revealing clinical symptoms were headache (3/7), seizure (3/7) or mild hemiplegia (1/7). Among those seven AVMs, 71% (5/7) were small (<3 cm) and 29% (2/7) were medium in size (3–6 cm). Venous drainage was superficial in 71% of the cases (5/7) and mixed in the remaining 29% (2/7). The main pathological basis of draining vein occlusion is venous thrombosis. Pathomechanisms proposed to explain spontaneous thrombosis of the draining vein are venous stagnation related to stenosis of the draining vein, alteration of the endothelium of the main draining vein, thrombophilia/acquired coagulation disorders and mass effect related to the nidus on the main draining vein [3, 4]. Based on the pathological mechanisms, the occlusion of draining vein is always permanent obliteration with a risk of bleeding [4]. In this case, The preoperative DSA showed that there was only little cortical venous drainage without main draining veins, which suggested a high risk of bleeding, and there was severe brain edema around the lesion. The spontaneous obliteration of AVM have similar clinical manifestations with conventional subtype. The revealing symptom of this patient was left limbs numbness. DSA showed that this malformation was supplied by distal branches of right MCA, and was through small cortical venous drainage. Bulky drainage venous thrombosis was found intraoperatively, which confirmed that this case was spontaneous occlusion of cerebral AVM due to drainage vein thrombosis. Treatment of an unruptured AVM with thrombosed main draining vein is not consensual. Previous studies indicated that low venous outlet draining meant a high risk of rupture [3]. Early interventional therapy or operation is recommended if surgical indications existed. A retrospective literature showed that four patients were managed conservatively and the other three were treated by interventional embolization.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgerySecond Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouChina
  2. 2.Brain Research Institute, Zhejiang UniversityHangzhouChina
  3. 3.Collaborative Innovation Center for Brain ScienceZhejiang UniversityHangzhouChina

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