Please cite this article in press as: Sy ECN, et al. Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation. Neurochirurgie (2018), https://doi.org/10.1016/j.neuchi.2018.04.005 ARTICLE IN PRESS G Model NEUCHI-926; No. of Pages 5 Neurochirurgie xxx (2018) xxx–xxx Disponible en ligne sur ScienceDirect www.sciencedirect.com Clinical case Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation E.C.N. Sy a,* , A. Melot b , L. Troude b , M. Al-Falasi b , H. Brunel c , P.-H. Roche b a Service de neurochirurgie, CHU de Fann Dakar-Sénégal, avenue Cheikh-Anta DIOP, 5035 Dakar, Sénégal b Service de neurochirurgie, hôpital Nord, 10700 Marseille, France c Service de neurochirurgie, hôpital Timone-adultes, 10700 Marseille, France a r t i c l e i n f o Article history: Received 12 November 2017 Received in revised form 20 February 2018 Accepted 13 April 2018 Available online xxx Keywords: Intracerebral hemorrhage Embolization Arteriovenous malformation Microsurgery a b s t r a c t Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24 hours post-embolization. This surgery was canceled due to a good angiographic result of the emboliza- tion. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures. © 2018 Elsevier Masson SAS. All rights reserved. 1. Introduction Therapeutic modalities of brain arteriovenous malformations include endovascular treatment, surgical excision and radio- surgery. Each case is discussed in a multidisciplinary meeting (MDM) to decide on the best option or therapeutic combination aimed at a complete angiographic occlusion of the malformation. Teamwork and coordination among the surgeon, endovascular sur- geon, and radiologist in management of AVMs is a prerequisite for a good outcome. For endovascular treatment, successful brain AVM obliteration was achieved in 13% of patients after emboliza- tion [1], which justified a combined treatment without delay with the surgery [2,3]. Cerebral ischemia is the most frequent complica- tion and intracerebral hemorrhage (ICH) remains the most serious complication after embolization [4]. The percentage of reported hemorrhagic complications related to embolization ranges from 2% to 4.7% [4,5]. The mechanisms and management of delayed ICH after treatment of brain AVM are poorly understood and widely debated [6]. The multiple theories and arguments surrounding ICH Abbreviations: AVM, arteriovenous malformation; MDM, multidisciplinary meeting; ICH, intracerebral hemorrhage; mRS, Modified Rankin Scale. * Corresponding author. E-mail address: cheikh-sy@live.fr (E.C.N. Sy). reflect the incomplete understanding of the complexity underlying pathophysiology and hemodynamics of brain AVM [6]. We will attempt to understand the factors that cause this serious complication based on our study and a comprehensive review of the literature. 2. Clinical case We report the case of a 61-year-old right-handed patient with a previous medical history of non-insulin-dependent diabetes and dyslipidemia. The patient was a smoker (60 packs/year) and obese with a BMI of 30. He was transferred to the emergency depart- ment after having had two generalized tonic-clonic convulsions with loss of urinary sphincter control during sleep. The neurolog- ical examination was normal, the Modified Rankin Scale (mRS) of the patient was 1. The cerebral CT scan with and without contrast agent injection performed urgently revealed a right frontal AVM without visible bleeding. Cerebral MRI confirmed the diagnosis of a right frontal AVM (F1) of approximately 3 cm with no signs of recent bleeding and moderate peri-lesional edema. The selective cerebral intra-arterial DSA showed an AVM location which was lat- eral frontal according to the Lawton classification, a compact nidus of about 2 cm with a supply from the anterior cerebral artery and the internal frontal branches of the right middle cerebral artery, https://doi.org/10.1016/j.neuchi.2018.04.005 0028-3770/© 2018 Elsevier Masson SAS. All rights reserved.