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Updated: Jun 16, 2025
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Timing of diffusion tensor imaging in the management of a ruptured pediatric arteriovenous malformation: illustrative
Jia-Shu Chen1,2, David J Caldwell2, Joseph A Falcone2,3
1The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Insights
Diffusion tensor imaging (DTI) in ruptured brain arteriovenous malformations (AVMs) may initially mislead. Repeating DTI after hematoma resorption provides a clearer picture for informed treatment decisions, preventing potential neurological deficits.
Area of Science:
- Neuroimaging
- Neurology
- Neurosurgery
Background:
- Diffusion tensor imaging (DTI) is used to assess white matter tracts near brain arteriovenous malformations (AVMs).
- Interpreting DTI in ruptured AVM cases is challenging due to blood products.
- This case highlights DTI's role in managing a ruptured pediatric AVM affecting the corticospinal tract (CST).
Purpose of the Study:
- To illustrate how serial DTI at different time points can inform treatment decisions for ruptured pediatric AVMs.
- To emphasize the potential pitfalls of initial DTI interpretation in ruptured AVM cases.
Main Methods:
- A 9-year-old female with a ruptured AVM underwent initial DTI showing CST compromise (reduced FA, FD, TC).
- Following a 6-week conservative management period for hematoma resorption, repeat DTI demonstrated improved CST integrity.
- Treatment strategy shifted from elective resection to stereotactic radiosurgery based on serial DTI findings and clinical status.
Main Results:
- Initial DTI suggested significant CST involvement, potentially leading to misinterpretation of white matter tract integrity.
- Serial DTI after hematoma resorption revealed partial nidus integration within intact CST fibers.
- Improvement in FA, FD, and TC on repeat DTI correlated with preserved motor function.
Conclusions:
- Initial DTI in ruptured AVMs can be misleading due to acute blood products.
- Serial DTI is crucial for accurate assessment of white matter tract integrity when delayed treatment is considered.
- Informed decision-making through serial DTI can prevent unnecessary interventions and permanent neurological deficits.
Background:
Diffusion tensor imaging (DTI) can characterize eloquent white matter tracts affected by brain arteriovenous malformations (AVMs). However, DTI interpretation can be difficult in ruptured cases due to the presence of blood products. The authors present the case of a ruptured pediatric AVM in the corticospinal tract (CST) and discuss how DTI at different time points informed the treatment.
Observations:
A 9-year-old female presented with a sudden headache and left hemiparesis. She was found to have a Spetzler-Martin grade III, Supplementary grade I AVM in the right caudate and centrum semiovale, with obliteration and corresponding reduced fractional anisotropy (FA), fiber density (FD), and tract count (TC) of the adjacent CST on DTI. The patient remained stable and was scheduled for elective resection following a 6-week period to facilitate hematoma resorption. After 6 weeks, repeat DTI showed part of the nidus within intact CST fibers with concordant improvement in FA, FD, and TC. Considering the nidus location, CST integrity, and motor function recovery, surgery was deferred in favor of stereotactic radiosurgery.
Lessons:
In ruptured AVMs, DTI may initially create an incomplete picture and false assumptions about white matter tract integrity. DTI should be repeated if delayed treatment is appropriate to ensure informed decision-making and prevent avoidable permanent neurological deficits. https://thejns.org/doi/10.3171/CASE24225.
