Unexpected Silent Infarctions after Embolization of Cerebral Arteriovenous Malformations and Fistulas: A Diffusion-Weighted Magnetic Resonance Imaging Study

We investigated the number and possible causes of clinically silent lesions seen in diffusion-weighted magnetic resonance imaging after embolization of arteriovenous malformations (AVMs) and fistulas using acrylate only or in combination with coils. Included were 19 patients with 18 AVMs and one case of a vein of Galen aneurysm in which 25 interventions were carried out. Results of diffusion-weighted imaging, the appearance of perinidal and distant lesions, were correlated to Spetzler grade, nidus size, flow, number of feeders occluded, rate of nidus occlusion and duration of the intervention. We found seven distant lesions corresponding to non-symptomatic infarcts in the given clinical setting. The only significant correlation between lesion size and parameters analyzed was the degree of nidus occlusion achieved during the intervention. Because most of the lesions presented in cases with a high occlusion rate, they appear to be related to the intention to reach a complete occlusion of the nidus. These results emphasize that the risk involved in eliminating the nidus completely must be reconsidered with special care, particularly in a situation where most high-flow feeders have been occluded.