case_images: PMC11153792_01
case_images: Serial cranial MRI examinations depicting the entire treatment and postoperative follow-up process of the patient; (A) Mid-sagittal cranial MRI in December 2018; (B) Axial cranial MRI in December 2021; (C). Mid-sagittal cervical MRI in December 2021; (D) Mid-sagittal cranio-cervical MRI in May 2022; (E) Mid-sagittal cranio-cervical MRI in June 2022; (F) Coronal spinal MRI in June 2022; (G) Axial cranial MRI in December 2023 (18 months postoperative); (H) Mid-sagittal cervical MRI (18 months postoperative); (I) Full spine X-ray (18 months postoperative). (J) Mid-sagittal cervical MRI (21 months postoperative); (K) The digital subtraction angiography(21 months postoperative); (L) Coronal spinal MRI in March 2024; *: AVM; (1). Hydrocephalus; (2). Empty sella syndrome; (3). Secondary CMI (Chiari malformation type 1); (4). Spinal syrinx; (5). Scoliosis; Yellow dashed arrow. The CSF shunt tube. Red dashed circle. Indicates the sign of midbrain sagging, referred to as the mamillopontine distance, with the specific measurement method available (4); Blue dashed line in Figure 1J represents the swollen boundary of the cerebellum; The yellow dashed line in Figure 1J delineates the boundary where the brainstem is tortuous and compressed.
case_images: fneur-15-1365525-g001.jpg
case_images: PMC11153792_01_fneur-15-1365525-g001.jpg
case_images: fig1
case_images: A follow-up cranial MRI showed no significant changes in the AVM, but revealed the emergence of mild hydrocephalus (Figure 1A). Chiari malformation") (Figures 1B,C). Considering the risks associated with surgery for this AVM, the neurosurgeon suggested using Antinociception for oral pain relief treatment (Table 1). Chiari malformation and a partially empty sella (Figure 1D). Considering the operative risk, the neurosurgeon recommended combining acetazolamide to reduce CSF secretion, continuously with Antinociception for oral pain relief treatment (Table 1). A cranial MRI revealed pronounced AVMP throughout (Figures 1E,F). MRI of the head showed: a completely alleviated obstructive hydrocephalus (Figure 1G), CMI, syringomyelia, an improvement empty sella (Figure 1H) and an unprogressive scoliosis (Figure 1I). However, the patient still exhibited significant congestion in the posterior cranial fossa, with the cerebellar tonsils notably displaced downward, although not to the extent that meets the diagnostic criteria for Chiari malformation (Figure 1J).
case_images: Patient's preoperative digital subtraction angiography (DSA) of the brain. (A-C) Deep cerebral arteriovenous malformation in the left temporal lobe with a diameter of approximately 4.52 cm x 3.65 cm. The left deep cerebral arteriovenous malformation in the left temporal lobe was primarily supplied by the left doublestem artery ( ) the left middle cerebral artery ( ) and the branch of the anterior cerebral artery ( ), draining to the straight sinus ( ) via the deep vein ( ) (the draining vein was dilated and blocked the foramen magnum and the three ventricles outlet). (D) Hemodynamic aneurysms are observed at the junction of the end of the left internal carotid artery (  approximately 4.2 mm) and the beginning of the M1 segment of the left middle cerebral artery ( , approximately 4.0 mm).
case_images: fneur-15-1365525-g002.jpg
case_images: PMC11153792_01_fneur-15-1365525-g002.jpg
case_images: fig2
case_images: Two hemodynamic aneurysms were observed at the junction of the end of the left internal carotid artery (#) and the beginning of the M1 segment of the left middle cerebral artery ( ) (Figure 2).
case_images: (A,B) The patient's Cranial MRI with 2D-Q-FLOW sequence preoperatively measured the patient's CVJ cerebrospinal fluid flow velocity in the mid-sagittal position. (A) the CSF flow velocity preoperatively in June 2022. It demonstrated an accelerated mean flow velocity in the aqueduct of sylvius (mean flow = 0.01 mL/s), the entrance to the four ventricles (mean flow = 0.00 mL/s), and the exit from the four ventricles (mean flow = 0.01 mL/s). Additionally, the flow area and total flow at the exit from the four ventricles are significantly reduced, as is the dorsal flow velocity in the craniocervical junction (mean flow = 0 mL/s). (B) CSF flow velocity postoperatively in December 2023. It demonstrated a slow mean flow velocity in the aqueduct of sylvius (mean flow = 0.0 mL/s), the entrance to the cisterna magna (mean flow = 0.01 mL/s), the exit from the quadrigeminal ventricles (mean flow = 0.02 mL/s), and recovery of the dorsal flow velocity in the craniocervical junction area compared to before (mean flow = 0.03 mL/s). (C,D) The patient's results from ocular coherence tomography (OCT) examination. (C) Preoperative OCT revealed the presence of bilateral severe papilledema. (D)The 18 months postoperatively, and the severe papilledema was completely relieved.
case_images: fneur-15-1365525-g003.jpg
case_images: PMC11153792_01_fneur-15-1365525-g003.jpg
case_images: fig3
case_images: The patient's mean CSF flow rate increased, whereas the mean flow amount decreased (Figure 3A). Bilateral severe progressive papilledema has been identified (Figure 3B). The results indicated that the patient's mean CSF flow rate was slower, and the mean flow amount was higher than before (Figure 3C).