Oculomotor neuropathy from an unruptured arteriovenous malformation in the frontal operculum: A case report
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Article Type:
Fadi Al Saiegh, Kevin Hines, Nikolaos Mouchtouris, Thana Theofanis, Pascal Jabbour, Robert Rosenwasser, Stavropoula TjoumakarisArticle Type:
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Fadi Al Saiegh, Kevin Hines, Nikolaos Mouchtouris, Thana Theofanis, Pascal Jabbour, Robert Rosenwasser, Stavropoula Tjoumakaris. Oculomotor neuropathy from an unruptured arteriovenous malformation in the frontal operculum: A case report. 28-Jun-2019;10:128
How to cite this URL: Fadi Al Saiegh, Kevin Hines, Nikolaos Mouchtouris, Thana Theofanis, Pascal Jabbour, Robert Rosenwasser, Stavropoula Tjoumakaris. Oculomotor neuropathy from an unruptured arteriovenous malformation in the frontal operculum: A case report. 28-Jun-2019;10:128. Available from: http://surgicalneurologyint.com/surgicalint-articles/9442/
Abstract
Case Description: The authors report the case of a 62-year-old male who presented with diplopia for 5 days. Magnetic resonance imaging and angiography demonstrated a Spetzler-Martin Grade 2 AVM located in the right frontal operculum with deep drainage into the basal vein of Rosenthal causing ipsilateral oculomotor neuropathy. The patient underwent staged embolizations of the feeding pedicles, which were derived from the internal as well as external carotid circulation. This was followed by a right pterional craniotomy for resection of the AVM. The patient reported complete resolution of the diplopia over 4 weeks with no recurrence at the 6-month follow-up appointment.
Conlusion: AVMs of the brain can present with atypical clinical symptoms that can be caused by the venous drainage pattern not the location. It is important to include vascular imaging studies in the work-up of patients who present with diplopia to rule out an AVM. Early diagnosis and treatment of the AVM can result in complete resolution of the diplopia.
Keywords: Arteriovenous malformation, Diplopia, Embolization, Endovascular, Microsurgery
INTRODUCTION
CASE REPORT
Figure 1:
(a) Axial T1-weighted magnetic resonance imaging (MRI) with gadolinium and (b) MR angiography show the arteriovenous malformations (AVM) located in the right frontal operculum and anterior insula with prominent venous drainage in the interpeduncular cistern. (c) Coronal T1 MRI shows medial extension of the AVM. (d) Anteroposterior (AP) angiogram of the right common carotid shows the AVM and its venous drainage into a tortuous basal vein of Rosenthal and vein of Galen. (e) AP of the right internal carotid (ICA) shows the AVM. (f) Lateral projection of the right ICA angiogram shows filling from middle cerebral artery branches.Figure 2:
Lateral (a) and anteroposterior (AP) (b) right external carotid angiogram showing filling of the arteriovenous malformations (AVM) through the middle meningeal (MMA), accessory meningeal (AMA), and sphenopalatine (SPA) arteries. Superselective catheterization of the SPA (c), AMA (d), MMA (e), just before Onyx-18 embolization. Lateral (f) and AP (g) projections of the external carotid artery post-embolization with Onyx-18 not showing any filling of the AVM from the external circulation.Figure 3:
(a) Lateral right internal carotid (ICA) angiogram in early to midarterial phase showing filling of the nidus from opercular middle cerebral artery branches. (b) Superselective catheterization of opercular branches in preparation for injection of Onyx- 18. (c) Lateral ICA projection after partial embolization of the arteriovenous malformations (AVM). Intraoperative AP (D) and lateral (E) common carotid angiogram showing complete resection of the AVM. The anterior cerebral circulation is not seen in this injection since it fills from the contralateral side.DISCUSSION
Central to this patient’s presentation is the high-flow shunting of blood across the nidus into tributaries of the basal vein of Rosenthal causing venous hypertension with increased tortuosity and dilatation of the vessel. The combination of direct mechanical compression and the transmission of pulsation onto the ipsilateral oculomotor nerve in the interpeduncular and crural cisterns was eventually responsible for the diplopia. A similar underlying mechanism is occasionally encountered in AVM-related trigeminal neuralgia. In such cases, AVMs located in the posterior fossa cause dilatation arteries and cause compression of the trigeminal nerve. Mori et al. reported a case of trigeminal neuralgia secondary to a vermian AVM that was successfully treated with endovascular embolization and radiosurgery.[3 ]
Our treatment strategy for this patient’s AVM consisted of embolization followed by surgical resection. We performed embolization in multiple stages since our institutional experience has shown that this approach reduces periprocedural complications such as ischemia and microcatheter trapping. This practice is also preferred by Mounayer et al. in their series of AVM embolization using Onyx.[4 ] Even though the AVM could not be cured embolization alone, it made microsurgical resection safer and more efficacious. In addition to reducing blood flow from surgically inaccessible feeders, the embolisate also helped define a dissection plane and reduced the duration of surgery.
CONCLUSION
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References
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