Vessel Wall Imaging, Flow, and Hemorrhage in the Draining Veins of Cerebral Arteriovenous Malformations

Aim Cerebral arteriovenous malformations (AVMs) demonstrate significant risk for hemorrhage, yet intervention also involves significant risk. The aim of this proof-of-concept study is to determine if Vessel Wall Imaging (VWI) technology may capture the draining veins of AVMs and, secondarily, if this technology may capture inflammatory processes in the walls of draining veins that correlate with rupture status. Methods Patients with a diagnosed cerebral arteriovenous malformation underwent T1-weighted fluid-attenuated inversion recovery imaging, with and without gadolinium contrast, to assess wall enhancement. Patients also underwent standard-of-care imaging, including digital subtraction angiography and magnetic resonance angiography. The presence of any (Y/N) and of circumferential (Y/N) draining vein, hemorrhage, AVM architecture, and clinical/demographic data was obtained for each patient. AVM flows were quantified using Non-invasive Optimized Vessel Analysis. Results VWI successfully captured venous wall contours in 8 of 9 cases studied; 1 case had a substantial hematoma that completely eclipsed venous anatomy. Post-gadolinium contrast enhancement in draining vein walls had a nearly-significant association with hemorrhagic presentation in the nidus. Post-gadolinium contrast enhancement was more prevalent in the draining veins of patients with a history of hypertension. There was a nearly-significant association of gadolinium wall enhancement in high-flow veins. Conclusion This proof-of-concept experiment successfully demonstrates that VWI technology is capable of capturing the tortuous anatomy of AVM draining veins. It also suggests that gadolinium-enhanced VWI is capable of capturing inflammatory processes exacerbated by factors such as hypertension and high-volume venous flow. Notably, this pilot study suggests that this technology may also be used to predict AVMs at highest risk of hemorrhage.