Glomus Cervical Arteriovenous Malformation Presenting with Intracranial Subarachnoid Hemorrhage: Clinical Case and Pial Resection Surgical Technique Description

Spinal intramedullary arteriovenous malformations (AVMs) can present with spinal hemorrhage. However, some of them occasionally can be the cause of angiographically negative intracranial subarachnoid hemorrhage, thus requiring a more comprehensive diagnostic approach to detect the possible source of bleeding. Nidal or arterial feeder aneurysms are widely considered high-risk rupture portions of the spinal AVM and recognized as a major cause of bleeding. Due to the tight eloquent confines within the thecal sac and the higher annual rupture risk after the initial bleeding, recurrent hemorrhage may have catastrophic outcomes. Hence the goal of management is to obliterate the spinal AVM preserving neurologic function and preventing future hemorrhagic events. Unlike cerebral AVMs, partial treatment of spinal intramedullary AVMs has been documented to be effective to improve the patients' prognosis dramatically. Microsurgical resection with or without adjuvant embolization has been considered the mainstay treatment for symptomatic glomus spinal intra-medullary AVMs. The case of a 25-year-old man with acute cerebral sub-arachnoid hemorrhage caused by intranidal aneurysm rupture of cervical glomus-type AVM is presented here. The patient was surgically treated by C3 -C4 laminectomy and AVM excision by pial resection technique. Thereby, the pial resection technique helps in providing subtotal AVM nidus resection, minimizing parenchymal dissection but effectively devascularizing glomus AVMs with satisfactory long-term results.