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Original research
Association of intracranial arteriovenous malformation embolization with more rapid rate of perfusion in the peri-nidal region on color-coded quantitative digital subtraction angiography
  1. Sphoorti Shellikeri1,
  2. Harrison Bai2,
  3. Randolph M Setser3,
  4. Robert W Hurst4,
  5. Anne Marie Cahill1
  1. 1 Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2 Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  3. 3 Siemens Healthineers, Malvern, Pennsylvania, USA
  4. 4 University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Sphoorti Shellikeri, Radiology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; shellikers{at}


Background Hemodynamic alterations post-embolization of intracranial arteriovenous malformations (AVMs) may cause delayed edema/hemorrhage in brain parenchyma adjacent to the lesion.

Objective To quantify and compare cerebral perfusion changes in the peri-AVM territory pre- and post-embolization using color-coded quantitative digital subtraction angiography (q-DSA).

Methods Pediatric intracranial AVM embolization procedures performed over a 5 year period were included. DSA images of all patients were retrospectively assessed using syngo iFlow. Regions of interest (ROI) were selected on anteroposterior and lateral q-DSA views: three in the peri-AVM region; two in parenchyma distant from the AVM. Time-to-peak (TTP) contrast enhancement of ROIs and ∆TTP (TTP at the selected ROI minus TTP at either the ipsilateral internal carotid/vertebral artery) were measured.

Result 19 pediatric patients with 19 AVMs (9 males/10 females, mean age 12 years) underwent intracranial AVM embolization: 15/19 AVMs were supplied by the anterior circulation and 4/19 by the posterior circulation. Blood flow was significantly slower post-embolization in the draining vein (19/19) (p<0.01), and the venous sinus outflow (17/19) (p<0.01), by mean difference of 2.01±1.31 s and 1.74±2.04 s. There was significantly increased peri-AVM parenchymal perfusion post-embolization (∆TTP=2.20±0.48 s) compared with pre-embolization (∆TTP=2.52±0.42 s), by an average ∆TTP of 0.33±0.53 s (p=0.014). In contrast, there was no perfusion difference (∆TTP=0.03±0.20 s, p=0.8) between pre- and post-embolization in the distant parenchyma. The size of the AVM was not correlated with change in peri-nidal parenchymal perfusion (r=−0.136, p=0.579).

Conclusion This study demonstrates more rapid perfusion in the peri-nidal brain parenchyma post-embolization of the AVM, which supports the theory that increased perfusion in normal tissue surrounding the AVM after embolization may underlie some post-procedural complications.

  • arteriovenous malformation
  • angiography
  • hemorrhage
  • intervention

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  • Contributors AMC and RH designed and directed the project. RMS supervised the work. SS performed the measurements, analysis of the results and wrote the manuscript with input from all authors. HB assisted in some patient follow-up measurements. All authors provided critical feedback and helped shape the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Only one author has a conflict of interest to be disclosed: RMS is an employee of Siemens Healthineers USA, which manufactured the imaging equipment. None of the other authors have conflicts of interest.

  • Patient consent for publication Not required.

  • Ethics approval Study was approved by the institutional review board of The Children’s Hospital of Philadelphia.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • No data are available. No data are available.