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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3644_Библиотеки_им_академика_М_И_Перельмана
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251Presentation
Fig. 4.12. A three-day-old neonate presented with moderate heart failure.Two separate AVFs were shown on internal carotid angiogram in AP (A) and lateral (B) views.
One was fed by the middle cerebral artery (long arrow) and the other by the anterior
choroidal artery (short arrow). The 3D angiograms before (C) and after embolization
(D) of the choroidal fistula with coils showed complete exclusion (arrow). The middle
cerebral artery fistula is being progressively occluded with coils (E,F).E,F see p.252
4Cerebral Arteriovenous Fistulas252
Fig. 4.12E,F. Legend see p. 251
Fig. 4.13A, B. A premature baby boy presented with neonatal respiratory distress.
The child was intubated and ventilated for 7days.At 4months,he developed cardiac
failure with hepatomegaly and splenomegaly initially felt to be related to a portocaval fistula. Transfontanel ultrasound revealed an enlargement of the subarachnoid
spaces and a pulsatile mass in front of the genu of the corpus callosum. Head circumference rapidly increased. MRI T1Win sagittal views (A, B) and internal carotid (C)
and selective anterior cerebral angiography (D) in lateral views revealed an arteriovenous fistula fed by a cingular branch of the anterior cerebral artery (arrow). Em-
bolization eradicated most of the lesion and resulted in improved cardiac status.Note
the residual intravascular angiogenesis (E, F).C–F see p.253
▲
253Presentation
Fig. 4.13E,F.Legend see p. 252
4Cerebral Arteriovenous Fistulas254
Fig. 4.14A–E. A 13-month-old child presented with
macrocrania related to a left frontal AVF. Postcontrastenhanced MRI T1 W mid-sagittal image (A) and lateral
view internal carotid angiogram (B) show an arteriovenous fistula fed by left anterior cerebral artery draining
toward the superior sagittal sinus with venous ectasia.
On the 1-year follow-up, carotid angiogram in lateral view
(C), the AVF is proven to be completely obliterated following two sessions of embolization with glue. The head
circumference normalized after embolization therapy,
which resulted in decreased dural sinus pressures and
remodeling of the dural sinuses as shown on the venous
phase of the carotid angiogram in AP views prior to
embolization (D) and on 1-year follow-up (E)
255Presentation
Fig. 4.15A–D. A 6-year old boy presented with headache and macrocrania at age
5years.MRI on axial (A) and sagittal view (B) demonstrated hydrocephalus related to
a huge ectatic vein at the level of the posterior fossa.Vertebral angiography on lateral
(C) and AP view (D) demonstrated right cerebellum AVF,fed by the right posterior inferior cerebellar artery (PICA), draining into the vein of Galen. Note the straight sinus
occlusion and the major supratentorial venous congestion. E–H see p.256
4Cerebral Arteriovenous Fistulas256
Fig. 4.15E–H. (continued) Selective PICA angiogram in lateral view (E) embolization
of the fistula was performed with pure glue (F).At 6 weeks of follow-up,vertebral angiography in lateral (G) and AP view (H) showed complete cure and already satisfactory vascular remodeling. One year later, he was neurologically normal and his
macrocrania stabilized
257Presentation
Ta ble 4.11. Revealing symptoms and symptoms at admission in patients with supratentorial CAVFs (41 patients) (Weon
et al. 2005)
Revealing symptoms No.of patients Symptoms at admission No. of patients
Cardiac insufficiency 13 (31.7%) Cardiac insufficiency 19 (46.3%)
Epilepsy
a
10 (24.4%) Neurologic deficit 14 (34.1%)
Macrocrania 6 (14.6%) Macrocrania 13 (31.7%)
Headache 4 (9.8%) Epilepsy 12 (29.3%)
Neurological deficit
b
3 (7.3%) Growth retardation 6 (14.6%)
Growth retardation 1 (2.4%) Headache 3 (7.3%)
Prenatal diagnosis
c
4 (9.8%) Epistaxis 2 (4.9%)
Exophthalmos 1 (2.4%)
To tal 41 (100%)
a
Five patients had their epilepsy associated with intracerebral, intraventricular,and/or subarachnoid hemorrhage.
b
One patient had transient facial palsy,another had visual loss,the remaining had progressive hemiparesis.
c
Two of them were diagnosed as cerebral AVFs and two as vein of Galen aneurysmal malformation. At birth three of
them had heart failure; one was asymptomatic.
Ta b l e 4 .12. Clinical features at presentation and on admission (one patient may have
multiple abnormalities) (14 patients) (Yoshida et al. 2004), infratentorial AVFs
Clinical features Patients (%)
At presentation On admission
Macrocrania 4 (28%) 5 (36%)
Headache 3 (22%) 5 (36%)
Neurological deficit from hemorrhage 3 (22%) 6 (43%)
Neurological deficit without hemorrhage
a
2 (14%)
Cardiac overload 2 (14%) 4 (28%)
Cerebellar symptom 0 2 (14%)
Retardation 0 3 (22%)
Incidental 0 1 (7%)
Epilepsy 1 (7%)
a
Brain-stem deficit.
4Cerebral Arteriovenous Fistulas258
Fig. 4.16A–D. A 19-month-old boy presented with a mild, slowly progressive motor
deficit on the right side for more than 1 year. MRI T2 W in coronal (A) and T1 W on
sagittal (B) views demonstrated multiple large areas of flow void along the ventral aspect of the brainstem and the left lateral aspect, significantly displacing the brainstem
and cerebellar structures. Vertebral angiogram in lateral (C) and AP (D) views
showed three separate AVFs (white arrows) fed by distal circumferential branches of
the vertebral arteries and draining into three large venous pouches, which in turn
drained upward toward the perimesencephalic venous system.E–I see p.259
259Presentation
Fig. 4.16E–I. (continued) Staged embolization
of the AVFs was performed,resulting in near
complete thrombosis of the venous pouches and
diminished mass effect, as shown on the MRI T2 W
in coronal (E,F) and T1 W on sagittal (F) views
obtained at 2.5 years of age. Follow-up vertebral
angiogram (G, I) demonstrates obliteration of most
AVFs and minimal flow in the third. Additional endovascular treatment will be explored while the
neurologically is nearly normal now
4Cerebral Arteriovenous Fistulas260
Fig. 4.17A–D. Legend see p.261
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