case_images: PMC7411175_01
case_images: (A,B) Intraventricular hemorrhage was noted on initial computed tomography (CT), and subsequent magnetic resonance imaging (MRI) revealed multiple signal-void vascular structures in the lateral ventricle with enlarged aneurysmal structures. (C,D) Preoperative digital subtracted angiography (DSA) revealed a distal AChoA aneurysm associated with an intraventricular arteriovenous malformation (AVM) with deep venous drainage via an enlarged internal cerebral vein and the great cerebral vein of Galen into the straight sinus, visualized in the early DSA. (E,F) The ultra-selective DSA [anteroposterior (AP) view (E) and lateral view (F)] in the operation showed that the microcatheter had crossed the most external point (MEP) of the anterior choroidal artery (AChoA), and the microcatheter tip rested on the right point, as our planned onyx reflux point was distal to the MEP.
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case_images: F1
case_images: Intraventricular hemorrhage was noted on CT, and subsequent MRI revealed multiple signal-void vascular structures in the lateral ventricle with enlarged aneurysmal structures (Figures 1A,B). In addition, there was a distal AChoA aneurysm near the nidus of the AVM distal to the MEP (Figures 1C,D). First, we deployed a microcatheter (Marathon) proximal to the aneurysm by ultra-selective DSA, and ultra-selective angiography confirmed that the microcatheter tip had navigated across the MEP, which was the correct location to occlude the AChoA by the PAO technique (Figures 1E,F).
case_images: (A,B) Intraoperative digital subtracted angiography (DSA) showed that the anterior choroidal artery (AChoA) was embolized distal to the embolization landmark (the MEP) by Onyx, and the ipsilateral capsulothalamic artery was retained [anteroposterior (AP) (A) and lateral (B) views]. (C,D) Postoperative computed tomography (CT) showed that the intraventricular hemorrhage had disappeared, the distal AChoA aneurysm and associated arteriovenous malformation (AVM) was embolized by glue (Onyx-18), and the Onyx cast was at the location of the distal AChoA aneurysm and the AVM in the left ventricle.
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case_images: F2
case_images: In addition, the proximal AChoA prior to the MEP with the ipsilateral capsulothalamic artery was retained (Figures 2A,B). Post-embolization CT revealed the glue cast within the previous lesion of the preoperative head MRI (Figures 2C,D).
case_images: PMC7411175_02
case_images: (A-C) Preoperative head computed tomography (CT) showed a left intraventricular hemorrhage, and axial magnetic resonance imaging (MRI) demonstrated a dilated artery and a suspected aneurysm in the left ventricle. (D,F) Preoperative digital subtracted angiography (DSA) [anteroposterior (AP) (D) and lateral (E) views] and 3D rotational angiographies (F) showed a narrowed internal carotid artery (ICA) bifurcation, A1, and M1 with Moyamoya change (Suzuki stage II-III). In addition, there was a dilated anterior choroidal artery with a distal aneurysm beyond the most external point (MEP).
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case_images: F3
case_images: A head CT scan revealed intraventricular hemorrhage in the left lateral ventricle, but the lateral, third, and fourth ventricles were not enlarged (Figures 3A,B). Axial MRI showed a dilated vessel, and a suspected aneurysm was found in the left lateral ventricle (Figure 3C). ICA bifurcation, A1, and M1 with Moyamoya change (Suzuki stage II-III). In addition, there was a dilated AChoA branch with a distal aneurysm beyond the MEP (Figures 3D-F).
case_images: (A-C) Ultra-selective digital subtracted angiography (DSA) at the plexal point (PP) (A) in the operation showed a large capsulothalamic artery arising at the PP. The ultra-selective DSA at the most external point (MEP) (B) showed two other branches arising at the MEP of the anterior choroidal artery (AChoA). The ultra-selective DSA (C) showed the microcatheter tip had crossed the MEP and another branch arising near the distal AChoA aneurysm. Therefore, we decided to embolize the aneurysm and the distal AChoA by coils. (D,E) Ultra-selective DSA (D) showed that the distal AChoA aneurysm and the AChoA beyond the MEP were embolized by coils, and DSA of the left internal carotid artery (ICA) (E) showed that there was no retrograde filling of the aneurysm by collaterals and that the ipsilateral capsulothalamic artery had been retained. (F) Postoperative head computed tomography (CT) showed that the AChoA aneurysm was embolized beyond the MEP with coils, and the intraventricular hemorrhage had disappeared.
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case_images: F4
case_images: Then, ultra-selective DSA was performed: ultra-selective DSA at the PP (Figure 4A) demonstrated a large capsulothalamic artery arising at the PP of the AChoA; ultra-selective DSA at the MEP (Figure 4B) showed two other branches arising at the MEP of the AChoA; and ultra-selective DSA (Figure 4C) beyond the MEP showed another branch arising near the aneurysm of the AChoA. Finally, the distal AChoA aneurysm and the AChoA beyond the MEP were embolized by coils (Axium; 2 mm x 3 cm, 2 mm x 1 cm), and DSA of the ICA showed that there was no retrograde filling of the aneurysm by collaterals and that the ipsilateral capsulothalamic artery had been retained (Figures 4D,E). Postoperative head CT revealed that the intraventricular hemorrhage had disappeared, and the coils were cast just in the location of the distal AChoA aneurysm in the occipital horn of the lateral ventricle (Figure 4F).