Acta Neurochirurgica 70, 81--88 (1984) ACTA NEUROCHIRURGICA 9 by Springer-Verlag 1984 Roentgen Division, Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland Variable Filling of an Arteriovenous Malformation During Carotid Angiography A Case Report By M. Porras, A. Servo, and J. J~i~iskinen With 4 Figures Summary An 11-year-old girl was operated on for a frontal arteriovenous malformation in 1978; a postoperative carotid angiogram showed no filling of the AVM. The patient still had epilepsy. In 1981 a carotid angiogram showed no AVM. Some months later a new carotid angiography was done. In the first lateral series no AVM was seen but on the second injection with one more millilitre of contrast medium a large frontal AVM became apparent. The reasons for such variable filling are discussed. Keywords." Arteriovenous malformation; brain; carotid angiography. Arteriovenous malformations (AVM) of the brain are developmental anomalies in the capillary segment of the vasculature. Anomalous vascular channels are nearly always identifiable angiographically 4. We present a patient who had been operated on for a frontal AVM. Three years later a carotid angiogram showed no AVM. Some months later, however, a new carotid angiography was done and on the first injection no A V M was seen but on the second injection a frontal A V M filled well. 6 Acta Neurochirurgica,Vol. 70, Fasc. 1 ~ 82 M. Porras et al.: Case Report An 11-year-old girl had had epileptic seizures, and a right frontal AVM was found in 1978 (Fig. 1). The AVM was operated on the same year; a postoperative carotid angiogram showed no filling of the AVM (Fig. 2). Because of persistent epilepsy, a right carotid angiogram was made under general anaesthesia in another hospital in 1981. It showed no AVM, but it did show a large, late frontal vein. In the same year the patient was admitted to the neurosurgical department, and right common carotid angiography was performed under local anaesthesia by direct puncture of the common carotid artery (4ml Citanest 1% without vasoconstrictive agent, Astra; 8 ml Isopaque cerebral 280 mg I/ml, Medica) and an automatic injector with an injection rate of 10 ml/second. Twelve films were exposed: 2 films/second for 2.5 seconds, 1 film/second for 1 second, and 1 film/2 seconds for 4 seconds). In the first lateral series no AVM was seen, only a large, late vein (Fig. 3). Because the basal part of the cerebrum was not visualized another lateral series was taken after five minutes. Nine millilitres of contrast medium were now used. This time a large frontal AVM with many early draining veins became visible. The feeding arteries were from branches of the pericallosal and middle cerebral artery (Fig. 4). The AP projection subsequently showed the AVM as well. The AVM was in the region which was totally visible in the first lateral projection too. So far the patient has not been re-operated. Discussion In o u r case there are t w o s t r a n g e points: 1. the first c a r o t i d a n g i o g r a m in 1981 s h o w e d n o A V M a n d 2. the s e c o n d c a r o t i d a n g i o g r a m at first did n o t s h o w the A V M b u t a second, larger injection o f c o n t r a s t m e d i u m r e v e a l e d it. A r t e r i o v e n o u s m a l f o r m a t i o n s o f the b r a i n c a n be seen in serial a n g i o g r a m s in 9 5 % o f cases. N o n - f i l l i n g is u s u a l l y c a u s e d b y a h a e m a t o m a c o m p r e s s i n g a small A V M or t h r o m b o s i s o f the A V M , or b e c a u s e the a n g i o m a is c a v e r n o u s 1,3 - 6, 8. A n e m b o l u s m a y also b l o c k the m a l f o r m a t i o n lO. T r a n s i e n t d i s a p p e a r a n c e o f an A V M h a s b e e n d e s c r i b e d a f t e r s u b a r a c h n o i d h a e m o r r h a g e la, epsilona m i n o c a p r o i c acid t r e a t m e n U a n d p o s t o p e r a t i v e l y 9. A n A V M w i t h a v e r y r a p i d or v e r y slow c i r c u l a t i o n m a y also r e m a i n u n d e t e c t e d in serial a n g i o g r a p h y s. I n technically p o o r a n g i o g r a m s A V M s c a n be missed, e . g . , if the injection goes m a i n l y into the e x t e r n a l c a r o t i d a r t e r y or into vessels n o t feeding the m a l f o r m a tion 2. Selective injection o f 10-15 m l o f c o n t r a s t m e d i u m into the i n t e r n a l c a r o t i d a r t e r y s h o w s u p the i n t r a c r a n i a l veins best, a n d also s h o w s u p the A V M s 11. O u r case d o e s n o t fit into a n y o f these r e a s o n s b e c a u s e the q u a l i t y o f the a n g i o g r a m s was g o o d . So the r e a s o n f o r the n o n - Figs. l a and b. Preoperative right carotid angiography January 31, 1978: a) arterial, b) venous phase. Frontal arteriovenous malformation (AVM) 9 9 ~z nl ~z .< Figs. 2 a and b. Postoperative right carotid angiography February I7, 1978: a) arterial, b) venous phase. No filling of the AVM r~ 4~ Figs. 3 a and b. Right carotid angiography October 20, 1981: a) arterial, b) venous phase. No AVM can be seen but a large, late vein 9 9 ~z Cr ~z ~z .< Figs. 4a and b. Right carotid angiography October 20, 1981 five minutes after Fig. 3 injection: a) arterial, b) venous phase. Good filling of the large AVM r~ Variable Filling of an Arteriovenous Malformation 87 filling of the A V M during angiography in another hospital is unknown. In the carotid angiogram done later in the same year in the neurosurgical department there were also no methodological differences between the first injection, during which the AVM did not fill, and the second injection, during which the A V M filled well, except for one more millilitre o f contrast medium in the second injection. The reason for improved filling may have been a change in the tone of the walls of the afferent arteries caused by the contrast medium or the local anaesthetic. A further but rather theoretical possibility is changes in the intracranial pressure through a Valsalva effect. Our case shows that carotid angiography m a y be unreliable in A V M patients and therefore postoperative angiography in these patients should be done with at least 10 ml of contrast medium, and preferably using a selective technique. 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