Transvenous Embolization of a Brainstem Arteriovenous Malformation Using 2 Balloons

Arteriovenous malformations (AVM) of the brainstem are a rare subgroup of vascular malformation that present a unique clinical and surgical challenge due to the anatomic location and life-threatening complications. Ruptured brainstem AVMs carry a higher risk of rebleeding and mortality. Various treatments including microsurgical resection, radiosurgery, and endovascular embolization have been used to treat brainstem AVMs with varying degree of success. Transvenous embolization of the AVM with flow arrest is an approach of growing interest that may offer curative elimination of AVMs. We present a technical report describing a case of a male in his 50s who presented with a ruptured AVM in the brainstem supplied by right superior cerebellar artery and basilar artery perforators. Venous outflow was via right sigmoid and straight sinuses. Young age with highly eloquent brainstem location and a prenidal aneurysm warranted a transvenous endovascular approach for obliteration of the AVM. The patient underwent transvenous liquid embolization of the brainstem AVM with selective simultaneous arterial and venous flow arrest in order to decrease intranidal flow and achieve higher nidal occlusion rates. A HyperGlide compliant balloon was employed in the basilar artery and a Scepter C balloon was employed in the internal cerebral vein to perform liquid embolization with Onyx. We describe a unique technique to treat brainstem AVMs using transvenous embolization, exemplifying the novel tactic of using arterial and venous flow arrest with balloons to achieve local limitation of flow in AVMs.