Evaluation of cerebral AVM's using transcranial Doppler ultrasound

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✓Blood flow velocities in basal cerebral arteries were recorded noninvasively in 28 patients with cerebral arteriovenous malformations (AVM's) and were correlated with the angiographic findings. In normal arteries remote from the AVM, flow velocities ranged from 44 to 94 cm/sec (median 65 cm/sec) with pulsatility indexes from 0.65 to 1.10 (median 0.87). This is consistent with findings in normal individuals. Arteries feeding the AVM's were identified by the high flow velocities (ranging from 75 to 237 cm/sec, median 124 cm/sec). The pulsatility index ranged from 0.22 to 0.74 (median 0.48). The difference of these results from findings in normal remote arteries was highly significant (p < 0.001). Hyperventilation tests illustrated the hemodynamic difference between an AVM and normal cerebrovascular beds.

Flow velocity measurements permitted noninvasive diagnosis of AVM's in 26 of the 28 patients. Furthermore, the identification of individual feeding arteries permitted good definition of the anatomical localization of individual AVM's. Flow velocity measurements combined with computerized tomography scans are useful in the diagnosis of AVM's. With the feeding artery's configuration identified on angiography, flow velocity measurements permit a new insight into the “hemodynamic dimension” of an AVM and its possible effects on adjacent normal brain-tissue perfusion in the individual patient.

Article Information

Address reprint requests to: Karl-Fredrik Lindegaard, M.D., Department of Neurosurgery, Rikshospitalet, Pilestredet 32, N-0027 Oslo 1, Norway.

© AANS, except where prohibited by US copyright law.

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Figures

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    Angiograms in a 27-year-old man. Left: Right carotid angiogram showing a large arteriovenous malformation of the right parietal region filling from the enlarged nontapering right middle and posterior cerebral arteries. Right: Left carotid angiogram showing cross-filling to the right middle cerebral artery (MCA) through the anterior circle of Willis. The left MCA illustrates progressive lumen reduction toward the periphery, which is characteristic of normal brain arteries.

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    Row velocity recordings from the same patient illustrated in Fig. 1. The recordings from the right middle and posterior cerebral arteries (MCA and PCA) show very high flow velocities (upper and lower left). The low pulsatility also clearly identifies these vessels as arteriovenous malformation-feeding arteries. Recordings from the normal remote left MCA and PCA show flow velocity and pulsatility within the normal range (upper and lower right). Recording from the left anterior cerebral artery (ACA) also has high flow velocity and low pulsatility (center right); this recording is shown below the zero line to indicate flow toward midline which is the normal direction for ACA flow. Recording from the right ACA shows retrograde flow with high flow velocity and a low pulsatility (center left), revealing its role as a feeding artery collateral to the right MCA. Flow velocities in the distal extracranial internal carotid artery were 85 cm/sec on the right side and 46 cm/sec on the left side (not shown).

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    Flow velocity and Doppler pulsatility index from recordings from 22 patients with medium-sized and large unruptured arteriovenous malformations (AVM's). Data from four patients with recent AVM hemorrhage are not included. There is a marked difference between values recorded from normal arteries remote from the AVM (squares), tapering feeding vessels (dots), and nontapering feeding vessels (circles). Lines connect values from each individual patient. In patients with multiple feeding vessels, the vessel having the highest flow velocity also showed the lowest pulsatility index. Collateral feeding vessels are not shown.

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    Location of 25 large and medium-sized cerebral arteriovenous malformations (AVM's) obtained from computerized tomography scans and angiograms (drawing of the left hemisphere used for graphic simplicity). Symbols denote AVM-feeding arteries; see below for explanation. The feeding arteries with the highest and the next highest flow velocities are indicated in patients with multiple feeding arteries to the AVM. Identification of individual feeding arteries permitted good definition of the anatomical location of individual AVM's. Arrows indicate three AVM's that were delineated directly. One cerebellar AVM fed by the superior cerebellar artery and two small AVM's that were not demonstrable from flow velocity measurements are not included. MCA = middle cerebral artery; PCA = posterior cerebral artery; ACA = anterior cerebral artery; V = velocity.

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    Left carotid angiograms in a 32-year-old woman. Left: Arterial phase showing an arteriovenous malformation in the left Sylvian fissure fed from the middle cerebral artery (MCA) trifurcation branches. Right: Venous phase showing normal distal MCA branches and draining veins with simultaneous opacification, illustrating rapid shunt flow. The arrow indicates the Sylvian fissure vein, and the arrowheads the sphenoparietal and superior petrous sinuses.

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    Recordings from the same patient illustrated in Fig. 5. Recording from the left middle cerebral artery (MCA) (upper left), at a sampling depth of 45 mm from the transducer, shows higher flow velocities and lower pulsatility than the recording from the normal right MCA (upper right). Recording at a sampling depth of 30 mm (at the arteriovenous malformation (AVM), center) reveals a broad Doppler spectrum with flow velocity directions toward and away from the probe simultaneously. The corresponding Doppler audio signal had a “machine-hall” quality due to the broad velocity spectrum. Recording from the Sylvian fissure veins (lower) had a “humming” audio-signal quality. Recording from the draining vein on the left side shows a higher flow velocity, about 40 cm/sec (lower left), and is more pulsatile than the signal recorded from the normal vein on the right side (lower right). This illustrates clear hemodynamic differences between AVM's and normal vascular beds. Flow velocities in the distal extracranial internal carotid arteries were 40 cm/sec on the right side and 46 cm/sec on the left side (not shown).

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    Recordings from a 53-year-old man in whom vertebral angiography had revealed a medium-sized arteriovenous malformation (AVM) of the left occipital region filled rapidly via an enlarged nontapering left posterior cerebral artery (PCA). A left carotid angiogram revealed filling of the AVM by a peripheral middle cerebral artery (MCA) branch with a diameter much smaller than the diameter of the proximal MCA (tapering feeder). The right carotid angiogram was normal. Upper: The recordings obtained at rest show typical differences between a nontapering feeder (left), tapering feeder (center), and normal remote arteries (right). Lower: On test hyperventilation, flow velocity level in the left PCA (left) increased from 132 to 134 cm/sec (2%) despite the end-tidal PaCO2 reduction from 38 to 28 mm Hg. At the same time, mean blood pressure increased from 93 to 100 mm Hg, which probably obscured any effect from CO2-reactive nutrient vessels distal to the measurement point. Flow velocity in the tapering feeder (left MCA, center) fell from 86 to 72 cm/sec (13% reduction), identifying this tapering feeder as also conveying nutritional flow. Flow velocity in the normal remote right MCA (right) decreased from 50 to 34 cm/sec (32% reduction), showing CO2 reactivity typical of normal brain flow.

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    Flow velocity changes recorded during test hyperventilation in 11 patients expressed as the percentage velocity change per mm Hg of induced PaCO2 reduction (vascular reactivity). The middle cerebral artery of the hemisphere contralateral to the arteriovenous malformation (AVM) represented normal arteries remote from the AVM. There is a clearly lower vascular reactivity in feeding arteries than in normal vessels. Moreover, vascular reactivity in nontapering feeding arteries differed as to whether blood pressure increased (cross-hatched bars), decreased (open bars), or remained the same (dotted bars), indicating that flow through the AVM itself does not respond to CO2 variation. Numbers over each bar denote number of vessels. Two feeding arteries were investigated in four patients.

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