• World Neurosurg · Aug 2021

    Symptomatic Unruptured Arteriovenous Malformations: Focal Oedema, Thrombosis and Vessel Wall Enhancement. A Retrospective Cohort Study.

    • Hans Kortman, Kartik Dev Bhatia, Thomas Wälchli, Patrick Nicholson, and Timo Krings.
    • Division of Neuroradiology, JDMI, University Health Network, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Division of Neuroradiology, ETZ Elisabeth Hospital, Tilburg, Noord-Brabant, the Netherlands. Electronic address: h.kortman@etz.nl.
    • World Neurosurg. 2021 Aug 1; 152: e467-e475.

    BackgroundFocal brain edema in unruptured brain arteriovenous malformations (AVMs) is rare and associated with venous outflow abnormalities and aneurysm growth. These patients have an increased rate of progressive neurologic symptoms, as well as a potentially increased risk of hemorrhage. In this study, we aim to assess in further detail the relationship between perifocal edema and enhancement of the vessel wall in symptomatic patients with an unruptured brain AVM.MethodsA single-center retrospective cohort study of all patients presenting with an unruptured AVM at Toronto Western Hospital from 2009 to 2019 was performed. Patients were included for review if they had focal edema surrounding an AVM on magnetic resonance imaging (MRI) and a contrast-enhanced MRI scan. Associated digital subtraction angiography studies were reviewed.ResultsA total of 122 patients presented with an unruptured AVM. Twelve symptomatic patients presented with focal edema surrounding the AVM. Six patients had focal edema and contrast-enhanced MRI performed. All 6 demonstrated luminal thrombosis at the level of the brain edema on MRI. Moreover, the vessel wall demonstrated enhancement at the level of the luminal thrombus in all.ConclusionsVessel wall enhancement, perifocal edema, and luminal thrombosis demonstrated in all patients with unruptured AVM points towards a common mechanism. We suspect an interplay between vascular hypoxia, the innate immune system, and thrombosis formation. Current research in the field of immunothrombosis supports this theory. Unravelling the mechanisms involved is important because it might guide therapy for patients with an unruptured AVM towards noninvasive options.Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

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