Retrieving microcatheters from Onyx casts in a series of brain arteriovenous malformations: a technical report.

INTRODUCTION: To date, the "monorail snare technique" for the retrieval of entombed microcatheter tips during Onyx(TM) (ev3, Irvine, CA) embolisation of brain arteriovenous malformations (BAVM) has not been described. We report our experiences and some technical aspects in using this technique for the retrieval of entombed Marathon(TM) microcatheter (ev3, Plymouth, MN) tips during Onyx embolisation of BAVM treatment. METHODS: Onyx was used in the embolisation of 11 patients using 25 feeders over 14 sessions. The 'monorail snare technique' was employed for 14 feeders. Each time, an Amplatz 4 mm Gooseneck Microsnare(TM) (ev3, Plymouth, MN) was loaded into an Excelsior 1018(TM) microcatheter (Boston Scientific, Natick, MA). The Marathon microcatheter was cut just distal to the hub, and the Amplatz/Excelsior combination was introduced along the length of the Marathon microcatheter towards its distal end, as far as possible. The embedded catheter was ensnared and both catheters were pulled free. RESULTS: Microcatheter tip removal was successful in all cases, except for one microcatheter tip becoming detached and needing no further intervention. There were no complications as a direct result of the snare technique. CONCLUSIONS: The monorail snare technique is a safe and easy technique for retrieving Onyx-encased microcatheter tips in the treatment of BAVM.

Reduced level of secretion and absence of subunit combination for the fibroin synthesized by a mutant silkworm, Nd(2).

Fibroin is normally composed of one H chain (350 kd) and one L chain (25 kd) which are connected by disulfide bond(s). However, the small amount of fibroin secreted into the lumen of the posterior silk gland of the Nd(2) (naked pupa) mutant does not contain L chain, although L chain mRNA is present and L chain is synthesized in the posterior silk gland cells of the mutant. In a hybrid silkworm, Nd(2)/Tamanashikasuri, where Tamanashikasuri is a normal producer of fibroin, L chain from the two alleles are distinguishable electrophoretically. It is demonstrated using this system that the L chain from the Nd(2) allele can combine normally with the H chain from Tamanashikasuri and the H-L complex is secreted normally. In another hybrid system, Nd(2)/J-131, where J-131 is a normal producer of fibroin, fibroin derived from the two alleles are distinguishable due to the different electrophoretic mobility of H chain. The fibroin derived from the J-131 allele is composed of H chain and L chain, while the fibroin derived from the Nd(2) allele is devoid of L chain, and its secretion is greatly reduced. We present evidence suggesting that the H chain derived from the Nd(2) allele is structurally abnormal and discuss how the H-L subunit structure is advantageous in the secretion of fibroin.

Sequence polymorphisms in the 5'-upstream region of the fibroin H-chain gene in the silkworm, Bombyx mori.

DNA fragments containing the fibroin H-chain gene from two different strains of Bombyx mori, J-139 and Nd (2) were cloned into phage lambda Charon 4A. Comparison of the restriction sites in these cloned DNAs revealed that in addition to the known polymorphism in the region coding for the repetitive amino acid sequence of the fibroin H-chain [Manning and Gage, J. Biol. Chem. 255 (1980) 9451-9457], at least two other types of polymorphism were present, one around the 5' end of the structural gene, and the other in the far upstream region of the gene. Restriction sites around the 5' end of the gene were well conserved between these strains, but some heterogeneity, suggesting the presence of small insertions, deletions or base changes, was noted. In contrast, DNA sequences of the region 2-4 kb upstream from the 5' end of the gene were markedly different between these two strains, indicating that either a deletion or an insertion of a DNA sequence longer than 2 kb had occurred in this region. Comparison with several other strains suggested that the observed changes in the far-upstream region were unique to the Nd(2) strain.

Studies on silk fibroin of Bombyx mori. I. Fractionation of fibroin prepared from the posterior silk gland.

1. Fractionation of fibroin prepared from the posterior silk glands of Bombyx mori was carried out. After carboxymethylation of the fibroin, it was fractionated by ammonium sulfate precipitation, Sephadex G-200 gel filtration and DEAE-cellulose column chromatography. 2. The fibroin was composed of at least two protein groups of large molecular size and three or four components of small molecular size, and, in addition, a mixture of proteins ranging in size from about 25,000 to more than 100,000 daltons with almost the same amino acid compositions. 3. The latter proteins contained about 48% glycine, 32% alanine, 11% serine, 4.5% tyrosine, 2% valine, and other minor amino acids. The sum of these main five amino acids accounts for more than 97% of the total amino acid residues of the proteins. 4. The present results indicate major heterogeneity in the molecular size of posterior silk gland fibroin, and, in addition, suggest the possibility of repeating sequences with relatively simple amino acid compositions in major peptide chains of fibroin.

The first component of polyphasic motor evoked potentials is resistant to suppression by paired transcranial magnetic stimulation in humans.

The suppressive effect of paired transcranial magnetic stimulation on the different components of motor evoked potentials (MEPs) from the left first dorsal interosseous muscle (FDI) was investigated in ten healthy human subjects. Conditioning stimuli were delivered via a round coil centered on the vertex, and test stimuli via a figure-eight coil over the right motor area. The threshold stimulus intensity of the minimally contracted FDI was determined with each coil. The stimulus intensities of conditioning and test stimuli were 80% and 130-140% of the threshold intensity, respectively. The coil current direction at the intersection of the figure-eight coil was medio-lateral. The coil position for test stimuli was adjusted to evoke discretely polyphasic MEPs in the contracted FDI. Conditioning stimuli were followed by test stimuli at intervals of 1-10, and 15 ms. When the interstimulus intervals were less than 5 ms, the second negative phase of MEPs was suppressed compared to that of the unconditioned responses, whereas the first phase was not suppressed. The present results imply that the first phase reflects direct corticospinal volleys, which are resistant to cortico-cortical inhibition.

Intraoperative use of real time ultrasonography applied to aneurysm surgery.

The intraoperative application of real time ultrasonography during 13 neurosurgical operations for intracranial aneurysms is reported. In 2 cases, the aneurysms themselves could be detected clearly by real time ultrasonic imaging. In the case of a large aneurysm, information about the nature of the aneurysmal wall was obtained. Other lesions coexisting with the aneurysm (namely, intracerebral hematoma, massive subarachnoid hemorrhage, and hydrocephalus) could be recognized clearly. Real time intraoperative ultrasonography is considered to be useful in aneurysm surgery.

Intramedullary clear cell ependymoma in the cervical spinal cord: case report.

OBJECTIVE AND IMPORTANCE: Clear cell ependymoma of the spinal cord has not been reported in the literature, although ependymoma in the cerebral and cerebellar hemispheres has been described. We present the first case report of this rare histological type of ependymoma arising in the cervical spinal cord and emphasize the importance of recognizing this histological entity. CLINICAL PRESENTATION: A 42-year-old woman presented with numbness in both upper limbs and spastic gait. Magnetic resonance imaging revealed an intramedullary tumor at the C6-T1 level with syringomyelia. INTERVENTION: The tumor was totally removed. Histological analysis revealed that the tumor was composed of round cells with perinuclear halos similar to those observed in oligodendroglioma. However, we diagnosed clear cell ependymoma because these tumor cells exhibited epithelial features and ependymal rosettes under light microscopic examination. CONCLUSION: Histological diagnosis was crucial to our determining whether to perform postoperative adjuvant therapy in this patient. Neurosurgeons should be aware of the possibility of this histological entity among intramedullary spinal cord tumors.

Relationship between contrast enhancement on computed tomography and cerebral vasospasm in patients with subarachnoid hemorrhage.

To elucidate the relationship between abnormal enhancement of the cisterns on computed tomography and cerebral vasospasm, we performed a systematic and prospective study in 60 patients with ruptured cerebral aneurysms. There is a significant relationship between the findings of contrast-enhanced computed tomography (CECT) within Day 3 of rupture and cerebral vasospasm. Among 37 patients undergoing CECT between Day 0 and Day 3, 17 (46%) showed prominent increases in density in the region around the circle of Willis and its branches. In 13 of 17 cases (76%), severe vasospasm with motor paralysis occurred. In the remaining 4 cases (24%) with only slight or no cerebral vasospasm, the hematoma in the subarachnoid space was removed surgically by Day 3. In 19 of 20 cases without remarkable CECT, no severe cerebral vasospasm with motor paralysis occurred. There is no significant relationship between the CECT findings after Day 3 and cerebral vasospasm. The results indicate that the prominent increase in density in the region of the circle of Willis and its branches often observed on CECT within Day 3 of subarachnoid hemorrhage is useful for prediction of the occurrence of cerebral vasospasm and also provide information on the pathogenesis of cerebral vasospasm.

Postoperative evaluation of extracranial-intracranial arterial bypass by means of ultrasonic quantitative flow measurement and computed mapping of the electroencephalogram.

As an objective evaluation of extracranial-intracranial (EC/IC) bypass operation, we studied 10 patients with occlusive cerebrovascular disease after EC/IC bypass operation using ultrasonic quantitative flow measurement (UQFM) and the computed mapping of the electroencephalogram (CME). After the operation, to evaluate the efficacy of the bypass operation, we studied all patients by UQFM and CME before and during compression of the superficial temporal artery (STA). In a control series of cases, the change in common carotid blood flow during STA compression was not statistically significant, and the findings of CME were unchanged during STA compression. In the cases with bypass surgery, reduction of the common carotid blood flow during STA compression was obvious and statistically significant (P less than 0.001). Additionally, in 5 of the 10 cases, the CME findings were aggravated during STA compression. Therefore, in these 5 cases the brain with bypass seems functionally dependent upon the bypass flow. It is suggested that the EC/IC bypass is effective at least in these 5 cases. The UQFM and the CME, which are noninvasive and simple, are very useful for postoperative evaluation of EC/IC bypass grafts from a hemodynamic and functional point of view.

Comparison of crystalloids and colloids for hemodilution in a model of focal cerebral ischemia.

Forty dogs were subjected to 6 hours of occlusion of the left internal carotid and middle cerebral arteries. They were divided into two "hemodilution groups" of 13 dogs each and a control "nonhemodiluted group" of 14 dogs. Thirty minutes after arterial occlusion, isovolemic hemodilution was performed by phlebotomy and infusions of low-molecular weight (MW) dextran in one group and of lactated Ringer's solution in the other group. The animals were sacrificed 1 week after temporary arterial occlusion. Hemodilution reduced the hematocrit to a level of 33% to 34%, which lasted throughout the week in both groups. After hemodilution there was a very significant reduction in blood viscosity, plasma total protein content, and fibrinogen levels in both groups in the acute stage; these levels gradually returned to baseline by the end of the week. In the group with lactated Ringer's solution hemodilution, both osmotic and oncotic pressures were decreased by hemodilution in the acute stage. In the control and low-MW dextran groups, osmotic and oncotic pressure remained unaltered throughout the week. Hemodilution resulted in a slight decrease in mean arterial blood pressure in all groups in the acute stage, but there were no significant changes in central venous, pulmonary arterial, or pulmonary wedge pressures. During the week of study, there were no differences in the cardiac index and total blood volume between the groups, and no significant changes in hematological parameters with the exception of a slight increase in bleeding time immediately after hemodilution with low-MW dextran. Daily neurological assessment showed consistently poorer condition during the first 5 days in the group with lactated Ringer's solution compared to either the control group or the group receiving low-MW dextran. Based on Mann-Whitney U-testing, the infarct volume of the lactated Ringer's solution recipients, expressed as a percentage of the total volume of that hemisphere (median 15.7%, range 6.6% to 25.2%) was significantly larger than that of the group receiving low-MW dextran (median 2.2%, range 0% to 15.8%) and that of the control group (median 11.9%, range 0% to 39.9%). The results indicate that, in this model, hemodilution with colloids was beneficial, whereas hemodilution with crystalloids was deleterious. It is likely that the decrease in oncotic pressure observed after hemodilution with lactated Ringer's solution is one of the most important reasons for its detrimental effect.

Isovolemic hemodilution in experimental focal cerebral ischemia. Part 1: Effects on hemodynamics, hemorheology, and intracranial pressure.

A total of 76 splenectomized dogs were entered in a study of the value and effects of isovolemic hemodilution. Of these, seven were not included in the analysis because of technical errors. Of the remaining 69 dogs, 35 were treated with hemodilution; 28 were subjected to a 6-hour period of temporary occlusion of the distal internal carotid artery and the proximal middle cerebral artery, and seven underwent a sham operation only, with arterial manipulation but no occlusion. The other 34 dogs were not subjected to hemodilution; 26 of these underwent temporary arterial occlusion and eight had a sham operation only. In each group the animals were about equally divided into 1) an acute protocol with regional cerebral blood flow measurements by a radioactive microsphere technique and sacrifice at the end of the acute experiment, and 2) a chronic protocol with survival for 1 week to permit daily neurological assessment and final histopathological examination but without blood flow measurements. Isovolemic hemodilution was performed about 1 hour after the arterial occlusion or sham operation and was accomplished by phlebotomy and infusions of low molecular weight dextran to bring the hematocrit to a level of 30% to 32%. This treatment resulted in a very significant reduction in viscosity and fibrinogen levels. The decrease in hematocrit lasted throughout the week in the animals in the chronic protocol. The decrease in viscosity correlated almost linearly with the decrease in hematocrit. There was a slight decrease in systemic arterial pressure with hemodilution but there were no significant changes in central venous pressure or in pulmonary arterial or wedge pressure. There was a slight decrease in cardiac index in both the hemodilution and control groups, which may have been due to the effects of barbiturate anesthesia. There was a slight increase in the measured blood volume in both groups, which was probably artifactual and related to the method of calculation. Intracranial pressure increased significantly with time in all animals subjected to arterial occlusion, but this increase was less severe in the hemodilution group. There was no significant change in intracranial pressure in sham-operated animals, whether hemodiluted or not. The results of cerebral blood flow measurements, assessment of neurological conditions, and measurement of infarct size are given in Part 2 of this report.

Isovolemic hemodilution in experimental focal cerebral ischemia. Part 2: Effects on regional cerebral blood flow and size of infarction.

Seventy-six splenectomized dogs were entered in a study of the value and effects of isovolemic hemodilution. Of these, seven were not included in the analysis because of technical errors. Of the remaining 69 dogs, 35 were treated with hemodilution; 28 were subjected to a 6-hour period of temporary occlusion of the distal internal carotid artery and the proximal middle cerebral artery, and seven underwent a sham operation only, with arterial manipulation but no occlusion. The other 34 dogs were not subjected to hemodilution; 26 of these underwent temporary arterial occlusion and eight had a sham operation only. In each group the animals were about equally divided into 1) an acute protocol with regional cerebral blood flow measurements by a radioactive microsphere technique and sacrifice at the end of the acute experiment, and 2) a chronic protocol with survival for 1 week to permit daily neurological assessment and final histopathological examination but without blood flow measurements. The general experimental protocol, the hemodynamic and rheological measurements, and the changes in intracranial pressure are described in Part 1 of this report. In the animals with arterial occlusion, blood flow decreased significantly in the territory of the ischemic middle cerebral artery. This decrease was partially reversed by hemodilution in the animals so treated. When the changes in blood flow before and after hemodilution in treated animals are compared with the changes at equivalent times in animals without hemodilution, the increases in flow in the gray matter of the ischemic hemisphere brought about by hemodilution are statistically significant. The neurological condition of the animals in the chronic protocol (sacrificed 1 week after occlusion) with hemodilution, as evaluated by daily neurological assessment, was significantly better than that of the control animals. In the animals sacrificed acutely (8 hours after arterial occlusion), the volume of infarction as estimated by the tetrazolium chloride histochemical method was 7.36% of the total hemispheric volume in the control animals and 1.09% in the hemodiluted animals, showing a statistically significant difference (p less than 0.005). In the chronic animals these values were 9.84% and 1.26%, respectively (p less than 0.005), as calculated by fluorescein staining. By histopathological examination the volume of infarction in the chronic animals was calculated as 10.92% in the control animals and 1.20% in the hemodiluted animals (p less than 0.005).(ABSTRACT TRUNCATED AT 400 WORDS)

Anaplastic meningioma with papillary, rhabdoid, and epithelial features: a case report.

A 74-year-old man manifested disturbed consciousness and right hemiparesis. Computed tomography revealed a left frontal parasagittal meningeal tumor with extensive peritumoral brain edema and skull invasion. Subtotal removal was performed. Five years later, he underwent two more operations of massive recurrences. Pathological studies revealed anaplastic meningioma with two different histological areas. One was an epithelial and meningothelial area, and the other was a papillary and rhabdoid area. In the papillary and rhabdoid area, small tumor cells with a high nucleus/cytoplasm ratio proliferated densely around the dilated central capillaries with a pseudopapillary pattern. Many rhabdoid cells (vimentin ++, cytokeratin AE1/AE3 +, epithelial membrane antigen [EMA] + +) tended to be distributed far from the central capillaries. There were many mitotic figures near the central vessels. Dense MIB1-positive nuclei were also observed near the central vessels. The trabecular pattern of the tumor cells in the epithelial area was quite different from the histological features of chordoid meningioma.

Expression of enzymes and oncogene induced after radiotherapy and/or chemotherapy in patients with brain tumors.

The relationship between the degree of the expression of Cu/Zn SOD, GST-pi and bcl-2 in the initial and recurrent tumor tissue after radiotherapy and/or chemotherapy and the cellular heterogeneity obtained from DNA content by image cytometry was investigated. Subjects were 7 patients who had glial tumors which were surgically removed at onset and removed a second time at recurrence. Radiotherapy and chemotherapy were also administered after initial resection. Immunoreactivity for copper/zinc super oxide dismutase (Cu/Zn SOD), GST (glutathione-S-transferase)-pi, and bcl-2 were evaluated from routinely prepared tissue blocks. Tumors were classified into two groups by cytometric analysis of DNA ploidy in the G2M cell cycle phase. One tumor group consisted of single clonal cells in both the initial and recurrent tumors and the other group consisted of tumors with polyclonal cells in the initial and recurrent tumor. In this study, one patient (case 3) with single clonal cell glioblastoma at recurrence did not show high Cu/Zn SOD activity after radiotherapy and chemotherapy but showed a short survival time after recurrence. In three patients (cases 1, 2, 3) with single clonal-cell glioblastoma, the recurrent tumor cells showed high GST-pi immunoreactivity and survival time was short after recurrence. Tumor cells in two patients (cases 5, 7) with single clonal cell anaplastic glioma at recurrence, showed high GST-pi immunoreactivity and had a short survival time after recurrence. In three single clonal glioblastomas (cases 1, 2, 3), the recurrent tumor showed the increased bcl-2 immunoreactivity and showed a short survival time after recurrence. In two patients (case 5, 7) with single clonal cell anaplastic glioma at recurrence, tumor cells showed a high bcl-2 immunoreactivity and these patients showed a short survival time after recurrence. Although the number of subjects is very small, our study shows that the immunoreactivity of bcl-2 and GST-pi in malignant gliomas may be very important factors in radio- and chemosensitivity, and shows that GST-pi is induced by radiation and anti-cancer drugs.

Normal brain damage after radiotherapy of brain tumours.

A total of 106 patients were examined for adverse effects to the brain from 60Co or proton radiotherapy. Radiation induced change (RIC) developed within the irradiated field 40-60 months after doses of 800-1000 neuNSD or 70 TDF and in 10-20 months after doses of more than 1700 neuNSD or 100 TDF. The incidence of RIC increased significantly with increasing age. Furthermore pathological changes like oedema and infarction in the brain tissue may be an important factor for the development of RIC in the central nervous system (CNS).

Effects of tazobactam on the frequency of the emergence of resistant strains from Enterobacter cloacae, Citrobacter freundii, and Proteus vulgaris (beta-lactamase derepressed mutants).

When Enterobacter cloacae, Citrobacter freundii, and Proteus vulgaris were treated with piperacillin (PIPC) in combination with tazobactam (TAZ), the in vitro frequency of emergence of resistant strains (beta-lactamase producing mutants) was lower than with PIPC or ceftazidime (CAZ) treated bacteria. In a mouse intraperitoneal infection model caused by E. cloacae, beta-lactamase derepressed mutants were detected following therapy with PIPC or CAZ, although no derepressed mutants were detected after treatment with PIPC in combination with TAZ. This suppression of the selection of derepressed mutants, which produce large amounts of beta-lactamases, by the combination of TAZ and PIPC suggests that the combination delays the increase of resistant mutants compared with PIPC alone.

Characterization of a new plasmid-mediated extended-spectrum beta-lactamase from Serratia marcescens.

A new extended spectrum beta-lactamase was detected in Serratia marcescens 42039 that was isolated from urine of patients with complicated urinary tract infection in Japan. This stain produced three different beta-lactamase types (TEM-1, a cephalosporinase, and a new beta-lactamase: CKH-1). The TEM-1 and CKH-1 encoding genes were conjugated from S. marcescens 42039 to Escherichia coli K-12 at frequencies of 10(-5) to 10(-6). The MICs of beta-lactams against the transconjugant were: ampicillin > 1600, piperacillin 800, cephalothin 1600, ceftazidime 6.25, cefotaxime 100, and ceftriaxone 200 micrograms/ml. The CKH-1 enzyme was purified to more than 90% by ion-exchange chromatography. The molecular weight of purified CKH-1 was 30 K dalton and the isoelectric point was 8.2. Relative Vmax/Km values (cephaloridine = 100) of penicillin G, cephalothin, and oxyiminocephalosporins such as cefuroxime, ceftriaxone, and cefotaxime, were 256, 226, 116, 87, and 49, respectively. The I50 values of tazobactam, BRL-42715, and clavulanic acid against CKH-1 enzyme were 0.0011, 0.0002, and 0.097 microM respectively. The enzymatic activity of CKH-1 was not inhibited by EDTA and anti-TEM-1 serum. These findings indicate that CKH-1 is a member of the groups of class A beta-lactamases. This is the first report of a plasmid-mediated oxyiminocephalosporin hydrolyzing broad-spectrum beta-lactamase from clinical isolates of S. marcescens.

SYN-1012: a new beta-lactamase inhibitor of penem skeleton.

A new beta-lactamase inhibitor, SYN-1012, with a penem skeleton was synthesized and its biological activity compared with clavulanic acid, sulbactam, tazobactam and BRL-42715. The beta-lactamase inhibitory activity of SYN-1012 was comparable to BRL-42715. Clavulanate and penam sulphones (sulbactam and tazobactam) were more active against TEM-1 and OXA-1, but were less active against TEM-3 and cephalosporinase (Case) than SYN-1012. In combination with piperacillin, SYN-1012 exhibited comparable or slightly lower synergistic effects than BRL-42715 against all the Gram-positive and Gram-negative isolates tested with only exception of Pseudomonas aeruginosa. The separate combinations of SYN-1012 and BRL-42715 with ceftazidime and cefotaxime provided comparable results against Gram-negatives, but not against Gram-positive isolates. Tazobactam was inferior to SYN-1012 in all cases. In comparison to tazobactam, SYN-1012 and BRL-42715 were relatively unstable in human and mouse plasma, and in mouse liver and kidney homogenates. Serum level of SYN-1012 and BRL-42715 after an intravenous administration of 20 mg/kg in rabbit was undetectable after 1 hour.

Chemical modification of tazobactam. Synthesis of 2 beta-[(4-substituted)-1,2,3-triazol-1-yl]methyl penicillanic acid sulfone derivatives.

A series of 2 beta-[(4-substituted)-1,2,3-triazol-1-yl] methyl penicillanic acid sulfones was synthesized as beta-lactamase inhibitors. Many of these compounds showed good in vitro inhibitory activity against penicillinase, cefotaximase and plasmid-mediated class III TEM enzymes, but exhibited weaker cephalosporinase inhibition. One member in this series--2 beta-[(4-pyridiniummethyl)-1,2,3-triazol- 1-yl]-6,6-dihydropenicillanate 1,1-dioxide (12a), when tested in combination with piperacillin, showed excellent synergistic activity against microorganisms producing plasmid-mediated enzymes, but had insufficient activity against microorganisms producing chromosomally mediated class I enzymes.

Venous malformation serving as the draining vein of an adjoining arteriovenous malformation. Case report and review of the literature.

BACKGROUND: Widely accepted pathologic classification of venous malformations includes discrete venous, arteriovenous, capillary, and cavernous malformations, each with distinct pathological criteria for definition. Several authors have described mixed or transitional vascular malformations with pathological features of more than one type of malformation within the same lesion. We present a rare case of a venous malformation associated with an arteriovenous malformation (AVM). CASE DESCRIPTION: A 37-year-old woman presented with a loss of consciousness. Computed tomography showed an enlarged vein running along the lateral wall of the right lateral ventricle. A cerebral angiogram demonstrated an AVM and a venous malformation in the right hemisphere; the AVM and the venous malformation were located in proximity to each other with the AVM using the venous malformation as its draining vein. In this case, where an AVM used the venous malformation as the draining vein, only the AVM was treated by proton-beam radiosurgery. Follow-up magnetic resonance angiography demonstrated complete obliteration of the AVM with the venous malformation remaining unchanged. CONCLUSION: Arteriovenous shunting would have disturbed venous drainage resulting in the development of the venous malformation. Thus, in addition to demonstrating a rare coexistence of AVM and venous malformation, this case also offers a new insight into the pathogenesis of these vascular malformations.