Vessel wall imaging and quantitative flow assessment in arteriovenous malformations: A feasibility study

Cerebral arteriovenous malformations (AVMs) carry a rupture rate of 2-3% per year. Several architectural factors may influence rupture rate, and a recently theorized model of AVMs describes the influence of vessel wall inflammation. A novel imaging modality, vessel wall imaging (VWI), has been developed to view inflammatory processes in vessel wall foci but has not yet been examined in AVMs, which is the aim of this study.

This retrospective review studies prospectively collected data on patients with ruptured and unruptured AVMs between 2019 and 2021. Inclusion criteria included adult patients (≥18 years) with radiographically diagnosed AVM who underwent VWI. Charts were reviewed for medical history, clinical presentation, hospital course, discharge condition, and follow-up. Angioarchitectural features, blood flow, and VWI were compared in patients with and without hemorrhagic patients.

Nine patients underwent VWI, mean age 37.7 ± 9.9 years. Four presented with hemorrhage (44.4%). Seven (77.7%) received glue embolization and 6 (66.7%) underwent surgical resection. All patients (4/4) with a history of hypertension presented with hemorrhage (p = 0.0027). Size and Spetzler-Martin grade were not associated with hemorrhage (p = 0.47, p = 0.59). Net AVM flow was higher in patients presenting with hemorrhage, although nonsignificant (p = 0.19). With VWI, 3 (75%) hemorrhagic AVMs showed visible nidus and draining veins, and all three demonstrated positive post-contrast wall enhancement in at least one of their draining veins; conversely, of fivenonhemorrhagic AVMs, only 2 (40%) demonstrated post-contrast wall enhancement in any draining vein (p = 0.090).

This pilot study successfully demonstrated capture of venous walls in AVMs using VWI. In this study, draining vein enhancement occurred more often in hemorrhagic AVM and in those with higher venous volumetric flow.