Delayed symptomatic haemorrhage from the remnants of a thalamic arteriovenous malformation after previous angiographic cure with radiotherapy

• Published in: Acta neurochirurgica Vol. 159; no. 11; pp. 2123 - 2125
• Main Authors: Majewska, Paulina, Tsui, Alpha, Adamides, Alexios A.
• Format: Journal Article
• Language: English
• Published: Vienna Springer Vienna 01.11.2017; Springer Nature B.V
• Subjects: Adolescent; Adult; Angiography; Angiography, Digital Subtraction; Blood vessels; Brain; Case Report - Vascular; Cerebral Angiography; Cerebral hemispheres; Cerebral Hemorrhage - etiology; Cerebral Hemorrhage - surgery; Disease Progression; Elastin; Female; Fibers; Fibrosis; Hemorrhage; Humans; Interventional Radiology; Intracranial Arteriovenous Malformations - complications; Intracranial Arteriovenous Malformations - diagnostic imaging; Intracranial Arteriovenous Malformations - radiotherapy; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Medicine; Medicine & Public Health; Minimally Invasive Surgery; Neurology; Neuroradiology; Neurosurgery; Neurosurgical Procedures; Parenchyma; Radiation therapy; Radiosurgery; Surgical Orthopedics; Thalamus; Thalamus - blood supply; Thalamus - surgery; Time Factors; Delayed haemorrhage; Angiographic cure; Arteriovenous malformation; Radiation
• DOI: 10.1007/s00701-017-3259-0
• ISSN: 0001-6268

In 1995 a 16-year old girl was diagnosed with a large left thalamic AVM that was considered unsuitable for microsurgical resection and was treated with radiotherapy twice, which led to angiographic cure. She re-presented 19 years after initial treatment with a symptomatic acute thalamic haemorrhage. Her digital subtraction angiography was negative for arterio-venous shunting. MRI/MRA showed cystic change with adjacent contrast enhancement in the region of the previously irradiated arteriovenous malformation. The patient underwent an interhemispheric transcallosal resection of the left thalamic haemorrhagic lesion via a contralateral craniotomy. Intra-operatively there was a cystic cavity filled with blood products in association with thrombosed, calcified vessels as well as actively filling vessels. Histologically there were aggregated abnormal blood vessels with a dilated lumen and surrounded by brain parenchyma. Some of the vessel walls were thickened with fibrosis and some were arterialised with presence of elastin fibres. Potential mechanisms for the delayed haemorrhage are discussed.