15 year old male presented with the following symptoms for 15 days
1.headache
2.slight bulging of the left eye
3. one episode of vomiting
MR suggests a brainstem AVM. Angiogram shows an AVM
Kindly opine on the mode of treatment for this boy.

MR and Angio images attached

Tags: AVM, brain, dalai, stem

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Challenging case, what are you going to do next? will you perform further selective angiography? will you consider Onyx procedure? I saw your video clip for another case, that was nice! Please let me know what is your decision and final result of this case, thanks.

Best regard,

Kuok
i think, there is very little arterial segment to come back for an onyx injection from arterial side.
I am thinking of going from the venous route with Onyx injection, Onyx-34 to form a plug and than
retrograde push of Onyx-18 into the nidus.
Reason: 1. No suitable arterial access 2. Single draining vein .

Opinions invited !!

Regards
Dalai
Possible but high risky procedure.
how about not doing an embolization?

Patient has not bled.
Its a small AVM.
No weak ares in the nidus or the feeding artery.
Improving symptoms on medication.

R
Dalai
Hi, Dalai,

will you consider cyber-knife therapy for this case? after all, it seems the nidus is not that big.

Kuok
Hi Siba,

the case seems very challenging and difficult to treat. I think that VM is symptomatic and needs treatment sooner or later. I would perform microangiography and possibly treat Glubran if possible. I see many tiny feeders difficult to embolize but you never know! I use mainly Onyx but i think it is not idicated in this case. My neurosurgical experience says that if you occlude inittially the single draining vein of an AVM (neurosurgically or endovascular ) it will explode. Neverthelless some interventionists like Prf Moret in Paris have described the retrogade method. Good luck . Please let us know!

Vasilis

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