Intracranial Haemorrhage Probably Due to an Angiographically Occult AVM after Carotid Stenting

Abstract

Angiographically occult vascular malformations refer to cerebrovascular malformations that are not demonstrable on technically satisfactory cerebral angiography.

Authors herein present a very unusual intracranial bleeding complication related to an angiographically occult vascular malformation after extracranial carotid artery stenting procedure.

A 52-year-old male patient admitted to the hospital with 2 episodes of amaurosis fugax in the left eye. Cervical carotid angiography and bilateral carotid Doppler ultrasonography revealed a 98% stenosis of the left internal carotid artery just distal to the bifurcation. Post-stenting control cervical carotid angiography revealed neither any residual stenosis nor a developmental venous anomaly.

The patient developed left pupil dilatation with loss of consciousness two hours after the neurovascular intervention. Emergent cranial CT showed acute subdural haematoma, intracerebral and subarachnoid haemorrhage with massive midline shift. He underwent an emergent craniotomy with left temporal lobectomy. Abnormal cortical vascular structures with prominent engorgement were remarkable over the posterior temporal cortex. Histopathological studies confirmed the diagnosis of an occult AVM

Classically, these lesions are not visualized with angiography. Our patient's cerebral angiography and MR investigations were all normal. To our knowledge this is the first case in literature in which intracranial haemorrhage (acute subdural haematoma, intracerebral haematoma, SAH) occurred due to hyperperfusion of angiographically occult vascular malformation.

Keywords

Angiographically occult vascular malformation intracranial haemorrhage carotid stenting hyperperfusion

Get full access to this article

View all access options for this article.

References

Crawford

Russell

: Cryptic arteriovenous and venous haematoma of the brain. J Neurol Neurosurg Psychiat 19: 1–11, 1956.

Becker

Townsend

: Occult cerebrovascular malformations. A series of 18 histologically verified cases with negative angiography. Brain 102: 249–287, 1979.

Cohen

Tucker

: Angiographically cryptic histologically verified cerebrovascular malformations. Neurosurgery 10: 704–714, 1982.

McCabe

Brown

: Fatal Cerebral Reperfusion Haemorrhage After Carotid Stenting. Stroke 30: 2483–2486, 1999.

Meyers

Higashida

: Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the craniocervical arteries. Neurosurgery 47: 335–345, 2000.

Qureshi

Luft

: Frequency and determinants of postprocedural haemodynamic instability after carotid angioplasty and stenting. Stroke 30: 2086–2093, 1999.

Ogilvy

Heros

: Angiographically occult arteriovenous malformations. J Neurosurg 69: 350–355, 1988.

Spetzler

Wilson

: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25: 651–672, 1978.

Sundt

Jr Sharbrough

: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: With results of surgery and haemodynamics of cerebral ischemia. Mayo Clin Proc 56: 533–543, 1981.

10.

Kapadia

Bajzer

: Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy. Stroke 32: 2328–2332, 2001.