Operation for delayed symptomatic brain oedema after treatment of an arteriovenous malformation by embolization and radiosurgery

A patient with a Spetzler-Martin-grade-III AVM, initially embolized and then stereotactically irradiated, who – with a latency of several months – showed progressive neurological deterioration, is reported. Magnetic resonance imaging revealed enormous ipsilateral brain oedema, which did not respond to dexamethasone. Upon further neurological deterioration the former AVM nidus plus an adjacent rim of brain tissue were removed and the patient recovered considerably. It is concluded that embolization in conjunction with irradiation may impair the blood-brain-barrier with resulting long-term oedema in the surrounding brain, and that surgical treatment should be considered in selected cases.