Recurrent cerebral arteriovenous malformations after negative postoperative angiograms

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✓ Angiography has been considered to be the gold standard to judge the success of treatment for cerebral arteriovenous malformations (AVMs). Patients without residual nidus or early draining veins on postoperative angiograms are considered cured, with the risk of hemorrhage eliminated. A series of five patients with recurrent AVMs after negative postoperative angiography is described. All patients had hemispheric AVMs, presented initially with hemorrhage, and were between 5 and 13 years of age. Recurrence was noted 1 to 9 years later (at 12–16 years of age); after a hemorrhage in three patients, seizures in one, and on follow-up magnetic resonance imaging in one. Four patients underwent angiography that showed recurrence of the AVM at or adjacent to the original site. Three years postsurgery, the fifth patient died from a large intracerebral and intraventricular hemorrhage originating in the previous location of the AVM; however, the patient did not undergo angiography at the time of recurrence. The initial negative angiograms obtained postoperatively in these patients may be explained by postoperative spasm or thrombosis of a small residual malformation. However, in the authors' cumulative experience with 808 patients who have undergone complete surgical removal of AVMs (of whom 667 were older than 18 years of age), no case of recurrent AVM has been observed in an adult. Therefore, actual regrowth of an AVM may occur in children and could be a consequence of their relatively immature cerebral vasculature and may involve active angiogenesis mediated by humoral factors. The present findings argue against the assumption that AVMs are strictly congenital lesions resulting from failure of capillary formation during early embryogenesis. It is concluded that delayed imaging studies should be considered in children at least 1 year after their initial negative postoperative arteriogram to exclude a recurrent AVM.

Article Information

Address reprint requests to: W. Jost Michelsen, M.D., Department of Neurological Surgery, The Montefiore Medical Center, 3316 Rochambeau Avenue, Bronx, New York 10467.

© AANS, except where prohibited by US copyright law.

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    Case 1. Left: A right internal carotid angiogram, lateral view, in an 8-year-old girl showing a 4 × 3-cm arteriovenous malformation in the orbitofrontal and anterior sylvian areas. Right: A postoperative right internal carotid angiogram, lateral view, documenting complete resection.

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    Case 2. Preoperative left internal carotid angiogram, lateral view (left), in a 6-year-old girl showing a small, diffuse arteriovenous malformation (AVM) (arrow) in the right posterior sylvian fissure fed by branches of the middle cerebral artery, which drains into an anterior sylvian vein (arrowhead). Seven days postsurgery, angiography documented complete resection. Nine years later, a right internal carotid angiogram, lateral view, (center) demonstrates a larger and more posteriorly located AVM that drains into the superior sagittal sinus via a large cortical vein (arrow). Note recruitment of lenticulostriate branches (arrow) on the anteroposterior view (right) to supply the malformation.

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    Case 3. A: Preoperative left internal carotid angiogram, lateral view, in an 11-year-old boy showing a 2.5-cm medioparietal arteriovenous malformation (AVM). B: One week after complete resection, an internal carotid angiogram demonstrated no residual AVM. The lateral view is shown. Vertebral injections also demonstrated no residual malformation. Three years later, he died from a hemorrhage located at the site of the previous AVM, and extending into the ventricle. Angiography was not performed. C and D: Noncontrast computerized tomography scans obtained on admission.

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    Case 4. Left: Left internal carotid angiogram, lateral view, showing a small arteriovenous fistula (arrow) located in the posterior superficial sylvian fissure. After interruption of the fistula and cauterization of a small collection of abnormal vessels, an intraoperative angiogram revealed no early draining veins or abnormal vascularity. Seven years later, after the patient developed seizures, a left internal carotid angiogram revealed a 3-cm arteriovenous malformation (AVM), more medially located and reaching into the ventricle. Right: Lateral internal carotid angiogram showing anterior choroidal supply to the AVM (arrow) not present in the original AVM.

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    Case 5. Left vertebral angiogram, anteroposterior view (A), demonstrating a small occipital arteriovenous malformation in a 13-year-old girl. Complete resection was followed by an angiogram 7 days later demonstrating no residual malformation or early draining veins; the anteroposterior view of the vertebral injection is shown (B), but the internal carotid angiogram was also negative. Fifteen months later a follow-up magnetic resonance image appeared suspicious for recurrence. Therefore angiograms were obtained (C and D) that revealed a small recurrent diffuse nidus at the site of the original lesion (arrows). The anteroposterior view of the vertebral injection (C) and the lateral view of the internal carotid artery injections are shown (D).

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