32 Right Temporal Hemorrhage in Pial Arteriovenous Malformation

Right Temporal Hemorrhage in Pial Arteriovenous Malformation

Clinical Presentation

A 32-year-old woman with no previous medical problems presented with a generalized epileptic seizure and mild headaches. She had no vascular risk factors except for being a smoker. She did not take any regular medication and did not have a known coagulopathy. On admission, the neurologic examination revealed no focal neurologic deficits and no meningeal signs. Her blood pressure was normal and drug screening was negative.

Initial Neuroradiologic Findings

Cranial CT on admission showed a right-sided temporal intraparenchymal hemorrhage (IPH) (Fig. B32.1).

Suspected Diagnosis

Atypical right temporal IPH of unknown cause. A cerebral venous thrombosis (CVT), arteriovenous malformation (AVM), or dural arteriovenous fistula (DAVF) was considered.

Questions to Answer by Ultrasound Techniques

Were there signs of extracranial or intracranial feeding arteries?
Were there signs of extracranial or intracranial draining or collateral veins?

Initial Neurosonologic Findings

Extracranial Duplex Sonography

Duplex sonography revealed normal findings in the carotid and vertebral arteries. In particular, both occipital arteries (OccA) showed normal flow parameters. The internal jugular vein (IJV) and vertebral vein (VV) showed normal flow signals on both sides.

Transcranial Duplex Sonography

Increased flow velocities with decreased pulsatility compared with the contralateral side were observed in the M1-segment of right middle cerebral artery (MCA) (flow velocity right 129/88 cm versus left 80/47 cm/s; PI right 0.40 versus left 0.58) (Fig. B32.2 and Fig. B32.3). The remaining intracranial arteries showed normal flow signals with regular pulsatilities. Assessment of the intracranial veins revealed normal flow signals and parameters in both basal veins of Rosenthal (BVR), the great cerebral vein of Galen (VG), the straight sinus (StS), and both transverse sinuses (TS) (not shown). In addition, a prominent arterial and a venous flow signal were detected in the right cortical/subcortical junction, insonated via the contralateral left transtemporal bone (axial plane, insonation depth 98 mm: arterial signal 149/103 cm/s, venous signal 96/70 cm/s). Considering the location, the vessels were interpreted to be a peripheral arterial feeder and venous recipient vessel of an AVM (Fig. B32.4). Searching for more atypical vessels via the same insonation approach, another prominent venous signal was detected at the subarachnoid/cortical junction at a depth of 108 mm (flow velocity 38/27 cm/s) (Fig. B32.5; see also Video 32.1). No circumscribed nidus could be detected. Global cerebral circulation time was not measured.

Conclusion

Suspected right-sided AVM in peripheral location with the right MCA as main arterial feeder and drainage via cortical veins.

MRI, MR Angiography, and Dynamic MR Angiography

MRI ruled out further bleedings. Time-of-flight MR angiography (TOF-MRA) showed prominent insular branches of the right MCA and an enlarged cortical vein which was also detectable upon review of the MRA raw data (Fig. B32.6). MR venography was normal without signs of CVT. Dynamic MRA finally proved the presence of a right temporolateral AVM (Fig. B32.7).

Conventional Angiography

Digital subtraction angiography (DSA), performed to assess therapeutic options, confirmed the findings from the dynamic MRA. In addition, a small feeder originating from a right posterior cerebral artery (PCA) branch was seen that had not been detected by the MRA (Fig. B32.8 and Fig. B32.9).

Fig. B32.1 Cranial CT, axial plane (A) and coronal plane (B) revealing a circumscribed right temporal hematoma (arrows).

Fig. B32.2 TCCS (transtemporal approach), right-sided insonation, midbrain plane. Mildly increased flow velocity and obvious decreased PI in the right M1-MCA (flow velocity 129/88 cm/s, PI = 0.40).

Fig. B32.3 TCCS (transtemporal approach), right-sided insonation, midbrain plane. Normal flow velocity and PI in the left M1-MCA at a depth of 86 mm (flow velocity 80/47 cm/s, PI = 0.58).