42-year-old woman with history of left temporal AVM treated with embolization and radiosurgery. The embolization was complicated by a retained microcatheter tip.
She now presents with aphasia.
PE: CN 2-12 intact
Strength 5/5 upper extremities and 5/5 right lower extremity.
Sensation intact to fine touch in upper ext. bilaterally and right lower extremity.
Significant word finding difficulty and expressive aphasia
EEG (5 day video)
Moderate epileptiform discharges localized to the left temporal lobe.
One electroclinical event originating from the left temporal lobe during which the patient opens her eyes, turns her head to the left, and has difficulty following commands as well as difficulty speaking. Postictally, the patient had trouble speaking that persisted even after she was able to follow commands and repeat.
The presence of a symptomatic cyst in the setting of a previously radiated AVM raises several important management issues. The overall treatment plan must (1) definitively rule out a residual vascular lesion, (2) exclude a radiation-induced malignancy, (3) establish the patient’s symptoms are referable to mass effect, and (4) surgically treat the cyst in a durable manner. These goals will be addressed in a stepwise fashion.
First, diagnostic cerebral angiography represents the gold standard for ruling out residual AVM and is an important initial management step. It informs the potential need to concomitantly treat the AVM at the time of cyst surgery or with other methods.
Second, sending cyst fluid for cytology helps exclude an underlying radiation induced glioma. Current brain tumor imaging guidelines do not support the use of MR Spectroscopy or PET to exclude malignancy. Surveillance MR imaging over time will likely buttress CSF findings that did not suggest malignancy in this case.
Third, subclinical seizures or transient ischemic attacks from the remote catheter retention history may alternatively explain the patient’s aphasic symptoms. The patient therefore underwent a negative, pre-operative EEG. Importantly, the patient had no MR evidence of past sub-clinical emboli and aspirin therapy resulted in no symptom improvement.
Surgical treatment of the cyst involves craniotomy for fenestration versus cystoperitoneal shunt. Small case series detailed in the references support shunting. The case of the month affirmed this observation in the literature. The patient initially underwent stand-alone fenestration to avoid permanent intracranial hardware. The patient developed a symptomatic recurrence within 3 months and required cystoperitoneal shunting. The patient now has complete resolution of her symptoms 6 months post shunting.
- Kim MS, Lee SI, Sim JH. A case of very large cyst formation with gamma knife radiosurgery for an arteriovenous malformation [Suppl]. Sterotact Funct Neurosurg 1999;2:168–174
- Flickinger JC, Kondziolka D, Lunsford LD, et al. A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Intl J Radiat Oncol 1999;44:67–74
- Pollock BE, Brown RD Jr. Management of cysts arising after radiosurgery to treat intracranial arteriovenous malformation. Neurosurgery 49:259–264
- Edmister, Lane, Brown and Pollack. “Tumefactive Cysts: A Delayed Complication following Radiosurgery for Cerebral ArterialVenous Malformations AJNR 26: 1152-1157 May 2005
1. The most likely etiology of the patient's baseline, progressive aphasia is:
2. The most likely diagnosis is:
3. Case series of this entity most support which surgical strategy?
4. Which of the following describes you?
5. I practice in one of the following locations.
6. Please add any suggestions or comments regarding this case:
- Though I placed 'observation with cyst surveillance', I would feel more comfortable with burhole endoscopic cyst fenestration/aspiration/cultures/histology and Ommaya reservoir placement with cyst catheter urgently. MRIs are not always accurate
- Would be helpful to have expert opinions on question 1 - 3 next month when the results are out. Unfortunately, this is not being done. It doesn't necessarily help to know what my colleagues across the globe think. It would be more educational if in addition we had an expert also discuss the case, even briefly.
- Would consider a vascular study to be sure there is no residual.
- Good case.
- This may include a radiation induced cavernous angioma
- Good case
- Very nice and case
- more info is needed regarding the interval between embolisation/radio surgery and onset of current presentation. Thanks
- Possible neuro navigation guided endoscopic cysto-ventriculostomy If not effective, cysto-peritoneal shunt
- Nice case.
- FOR THIS PROBABLE RADIATION INDUCE LESION THE USE OF VITAMIN E AND TRENTAL 400 COULD BE OF SOME INTEREST
- With a crenotomy and fenestration it is not comopletely resected the membranes of the cyst and it is a cause of regrowing. In the other hand if it is an abscess then it could be enough with the craniotomy and fenestration.
- Interesting case.Thank you. Kindest Regards Tomasz Skaba
- What is the time from the procedure to the MRI??? Thats a key to the answers.
- The cause of the dysphasia may be mulifactorial (Cyst, residual AVM, epilepsy) We are not told when the treatment was undertaken in relation to the onset of the dysphasia. She needs treatment with antiepileptics, and a craniotomy to drain the cyst, remove the residual AVM and hopefully remove the retained catheter tip with it.
- thank you
- Rare presentation of avm with glioma,which on this casr z most likly cystic glioms,as patient z symptomstic and mri shows cystic lesion with mass effect ideally craniotomy and aspiration cystic fluid and excision of Wa'll should b done.