Intracranial Gorgon: Surgical Case Report of a Large Calcified Brain Arteriovenous Malformation

Cerebral arteriovenous malformation calcifications: A systematic review, case series, and a proposed classification system

Background

Brain arteriovenous malformations (AVMs) are intracranial vascular lesions characterized by a nidus of vessels fed by an artery and drained by a vein, lacking intervening capillaries. Angiography remains the gold standard for a definitive diagnosis. There is a paucity in the literature regarding clinical presentation and management of patients with calcified cerebral AVM (cCAVM). This study aims to highlight the clinical presentation and management of patients with cCAVM and also to propose a classification of calcification patterns in cCAVMs based on brain computed tomography (CT) findings.

Methods

A systematic review using PubMed, Scopus, and Web of Science was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify cases that illustrate cCAVM. A case series was also presented to supplement the current literature.

Results

Twenty patients with cCAVM were included, with the male gender representing more than 50% of the patient population. Their age ranged from 11 to 69 years, with seizures being the most common presenting symptom. The frontal lobe was the most common location of AVMs, followed by the parietal lobe. Most (80%) of the calcifications were nidal, with the remaining being extranidal (20%).

Conclusion

The CT scans of patients displayed significant variability due to the unique characteristics of each cCAVM. To address this diversity, a novel classification system was developed to provide a comprehensive framework for understanding cCAVMs based on their location, size, and extent.

The Nightmare of AVM Surgery: Early Rupture of the Venous Drainage-Lessons from Personal Experience and a Review of the Literature

We describe the case of a 72-year-old man who presented with signs of increased intracranial pressure, right-sided motor deficit, and repeated episodes of epilepsy due to a left frontal arteriovenous malformation (AVM) with a large superficial draining vein. Despite great efforts to protect the vein from the start, it ruptured shortly after we removed the bone flap. This required rigorous hemorrhage control, which in turn led to profuse bleeding from the nidus throughout the process of the dissection and coagulation of the arterial feeders. The postoperative course was initially uneventful; however, the patient declined neurologically and became unresponsive on the second day after surgery. Emergent CT revealed a significant hematoma occupying the space where the AVM nidus had been resected. The patient was taken back to the OR for emergency evacuation of the hematoma. Despite these efforts, the neurological status remained poor, and the patient was transferred to a territorial hospital after spending 3 weeks in the ICU.An early rupture of the venous drainage represents a dreaded complication of AVM surgery, which can compromise the intervention before the start of the definite resection. We discuss our experience of and strategy for preventing and managing the intraoperative venous rupture of AVMs by describing our seven rules of "Don't." We also provide a brief overview of the relevant literature.

Pediatric intracranial calcified arteriovenous malformation: A case report

Background:

Brain arteriovenous malformations (AVMs) are intracranial lesions that consist of a complex tangle of abnormal blood vessels. They can occasionally become hard and calcified. This may render these lesions difficult to resect and lead to neurological complications. There are very few reported cases of calcified brain AVMs in the literature.

Case Description:

We report the case of an 11-year-old patient who presented with headaches and seizures exacerbated in the past 3 months. Preoperative imaging confirmed a large, right parasagittal AVM, with significant internal calcifications seen on the computed tomography angiogram. We performed a successful microsurgical resection of the calcified AVM and confirmed the diagnosis on histopathological analysis.

Conclusion:

Dense internal calcifications within AVMs are a clinical rarity and can be challenging cases for microsurgical resection.