Benefit of cone-beam computed tomography angiography in acute management of angiographically undetectable ruptured arteriovenous malformations

Clinical article

Jason P. Rahal M.D. and Adel M. Malek M.D., Ph.D.
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  • Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center, and Tufts University School of Medicine, Boston, Massachusetts
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Object

Ruptured arteriovenous malformations (AVMs) are a frequent cause of intracerebral hemorrhage (ICH). In some cases, compression from the associated hematoma in the acute setting can partially or completely occlude an AVM, making it invisible on conventional angiography techniques. The authors report on the successful use of cone-beam CT angiography (CBCT-A) to precisely identify the underlying angioarchitecture of ruptured AVMs that are not visible on conventional angiography.

Methods

Three patients presented with ICH for which they underwent examination with CBCT-A in addition to digital subtraction angiography and other imaging modalities, including MR angiography and CT angiography. All patients underwent surgical evacuation due to mass effect from the hematoma. Clinical history, imaging studies, and surgical records were reviewed. Hematoma volumes were calculated.

Results

In all 3 cases, CBCT-A demonstrated detailed anatomy of an AVM where no lesion or just a suggestion of a draining vein had been seen with other imaging modalities. Magnetic resonance imaging demonstrated enhancement in 1 patient; CT angiography demonstrated a draining vein in 1 patient; 2D digital subtraction angiography and 3D rotational angiography demonstrated a suggestion of a draining vein in 2 cases and no finding in the third. In the 2 patients in whom CBCT-A was performed prior to surgery, the demonstrated AVM was successfully resected without evidence of a residual lesion. In the third patient, CBCT-A allowed precise targeting of the AVM nidus using Gamma Knife radiosurgery.

Conclusions

Cone-beam CT angiography should be considered in the evaluation and subsequent treatment of ICH due to ruptured AVMs. In cases in which the associated hematoma compresses the AVM nidus, CBCT-A can have higher sensitivity and anatomical accuracy than traditional angiographic modalities, including digital subtraction angiography.

Abbreviations used in this paper:AP = anteroposterior; AVM = arteriovenous malformation; CBCT-A = cone-beam CT angiography; CTA = computed tomography angiography; DSA = digital subtraction angiography; ICA = internal carotid artery; ICH = intracerebral hemorrhage; MIP = maximum intensity projection; MPR = multiplanar reconstruction; MRA = MR angiography.

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Contributor Notes

Address correspondence to: Adel M. Malek, M.D., Ph.D., Department of Neurosurgery, Tufts Medical Center, 800 Washington Street #178, Proger 7, Boston, Massachusetts 02111. email: amalek@tuftsmedicalcenter.org.

Please include this information when citing this paper: published online May 17, 2013; DOI: 10.3171/2013.4.JNS1390.

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