Cerebral haemorrhage from a remote varix in the venous outflow of an arteriovenous malformation treated successfully by embolisation

Abstract

ABSTRACT. The ''spot sign '', described in 2007, has shown that a focal area of contrast extravasation within an intracerebral haematoma (ICH) can be correlated with haematoma expansion. Here we describe a case where time-resolved dynamic CT angiography (dCTA) shows the appearance of the ''spot sign'' only in later images. This shows the importance of timing of static CT angiogram that, if performed too early, might result in a false negative diagnosis. Haemorrhage in patients with intracranial arteriovenous malformation (AVM) usually occurs from the AVM itself or from an associated arterial aneurysm. We report a case of intracerebral haemorrhage arising from a remote varix related to the venous outflow of an ipsilateral frontal AVM. Case reportA 63-year-old male was admitted following a sudden onset of headache associated with neck stiffness and visual disturbances. There was no history of loss of consciousness or focal neurological deficit. On examination, the patient was photophobic and had nuchal rigidity. A visual field test showed a right homonymous hemianopsia but there were no other focal neurological signs.A non-enhanced CT of the brain ( Figure 1a) showed a large left temporal lobe intracerebral haemorrhage with secondary intraventricular and subarachnoid haemorrhage. There was also a calcified lesion in the left frontal lobe (Figure 1b), consistent with calcification within an AVM. A CT angiogram confirmed the presence of a left frontal AVM. An enhancing vascular structure adjacent to the left temporal lobe haematoma (Figure 1c) was demonstrated, representing either a flow aneurysm or a varix. MRI brain (Figure 1d) showed a left temporal intracerebral haematoma with an adjacent spherical area of flow void (Figure 1e), consistent with an aneurysm or varix. An AVM was noted in the left middle frontal gyrus (Figure 1d), distal from the area of haemorrhage. MR angiography (Figure 1f) showed enlarged arterial feeders arising from the left anterior and middle cerebral arteries.The conventional cerebral angiogram (Figure 2) confirmed the presence of a left frontal AVM (SpetzlerMartin grade 1-0-0) that was mainly supplied by branches of the left internal carotid artery. No arterial flow aneurysm was noted. The AVM had a peculiar way of draining. A primary single large collecting vein was divided into several smaller veins, majority of which were draining into the superior sagittal sinus via communication with superficial cortical veins. There was a single vein with a posteroinferior course. During late venous phase, two varices were seen on this vein (Figure 2c, f). Various degrees of stenoses were seen in the peripheral draining veins. The varix, adjacent to the area of haemorrhage, showed impaired outflow because of stenosed segments ( Figure 2f) and was probably the most vulnerable part of this AVM with regard to haemorrhage.During embolisation, the major right prefrontal middle cerebral artery feeder was initially catheterised and the tip of the microcatheter was placed intranidally within the AVM (Figur...

Trigeminal Neuralgia due to an Isolated Cerebral Varix: Case Report

“…5,6 Isolated cerebral varix is a rare entity that usually occurs on a high-flow vein of arteriovenous fistulas or arteriovenous malformations. 1,2 It is also found in relation to developmental venous anomalies. 7,8 However, the venous varix is rarely an isolated lesion without any relation to these vascular anomalies.…”

“…Isolated cerebral varices are commonly reported in relation to high-flow draining veins of arteriovenous fistulas, arteriovenous malformations, and venous angiomas. 1 2 Although they usually appear without neurologic symptoms, there are a few reports of symptomatic cases with hemorrhage or mass effect. 3 4 To the best of our knowledge, there is no report that an isolated cerebral varix causes trigeminal neuralgia.…”

Intracerebral hemorrhage: toward physiological imaging of hemorrhage risk in acute and chronic bleeding

“…Acquiring dynamic images demonstrate the evolution of contrast extravasation, including Spot Sign presence and post-contrast leakage. A single report using dynamic CTA identified delayed contrast extravasation in a purportedly CTA Spot Sign negative hemorrhage (Chakraborty et al, 2010). Disadvantages of such acquisitions include increased radiation dose and the large amount of raw data acquired.…”

Transvenous Coil-plugging Technique for a Symptomatic Giant Varix Associated with Arteriovenous Malformation

“…1) As it contributes to the development of bleeding or mass effect, nidus is usually treated with direct surgery or stereotactic radiosurgery with or without endovascular techniques. [2][3][4] However, therapeutic interventions targeting a varix itself are uncommon because unexpected interruption of the drainage route can cause rupture of the nidus. Here, we report a rare case of transvenous treatment of a giant varix.…”