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Abstract
Introduction Arteriovenous malformations (AVM) of the ambient cistern are an extremely rare subgroup of vascular malformation that present a unique clinical and surgical challenge due to the anatomic location and life-threatening complications. Ruptured brain stem AVMs carry a higher risk of rebleeding and mortality. Various treatments including microsurgical resection, radiosurgery and endovascular embolization have been used to treat brainstem AVMs with varying degree of success. Transvenous embolization of the AVM with flow arrest is an approach of growing interest which may offer curative elimination of AVMs.
Methods We present a case report of a 52 year-old male who presented with a ruptured Spetzler-Martin Grade 3 AVM in the ambient cistern supplied by right superior cerebellar artery and basilar artery perforators. Venous outflow was via draining veins into the right sigmoid and straight sinuses. The highly eloquent brainstem location, along with a pre-nidal aneurysm arising from a basilar artery perforator and young age of the patient with high risk of rebleeding warranted a transvenous endovascular approach for the obliteration of the AVM.
Results Patient underwent transvenous liquid embolization of the brain stem AVM with selective simultaneous arterial and venous flow arrest in order to decrease intra-nidal flow and achieve higher nidal occlusion rates. A HyperGlide™ compliant balloon was employed in the basilar artery to provide arterial flow arrest while a Scepter C™ balloon was employed in the internal cerebral vein to perform liquid embolization with OnyxTM. Complete obliteration of the AVM was achieved using this technique.
Conclusion We add to the few reports of brain stem AVMs treated with transvenous embolization in the literature, while also exemplifying the unique tactic of using arterial and venous flow arrest with balloons to achieve local limitation of flow in the AVM.
Disclosures S. Thanki: None. M. Monsour: None. E. Pressman: None. K. Vakharia: None.