Medial-type persistent trigeminal artery and ipsilateral posterior communicating artery supplying bilateral posterior cerebral arteries combined with an aberrant right subclavian artery and bicarotid trunk.

PURPOSE: To describe a case of a medial-type persistent trigeminal artery (PTA) associated with multiple arterial variations. METHODS: A 34-year-old woman with multiple sclerosis underwent cranial magnetic resonance (MR) angiography from the aortic arch to the neck region and intracranial region for the evaluation of an unruptured cerebral aneurysm that was previously detected on MR imaging. The MR machine was a 3-T scanner. RESULTS: There was an aberrant right subclavian artery and bicarotid trunk, medial-type left PTA and ipsilateral posterior communicating artery (PCoA) supplying bilateral posterior cerebral arteries (PCAs). The unruptured aneurysm was located at the paraclinoid segment of the left internal carotid artery and was treated successfully by coil embolization via a transfemoral approach. CONCLUSION: Only 10% of PTAs are classified as the medial type. The association with extremely large ipsilateral PCoA, which supplies the bilateral PCAs, has not been previously reported. Aberrant right subclavian arteries are common and are frequently associated with a bicarotid trunk. Before catheterization of the cerebral arteries, the aortic arch and its branches must be evaluated by MR angiography or computed tomography angiography to prevent catheterization failure via the right transradial approach.

Ascending pharyngeal artery-posterior inferior cerebellar artery anastomosis via the jugular foramen: a case report and literature review.

The posterior inferior cerebellar artery (PICA) rarely arises from the cavernous segment of the internal carotid artery (ICA) and is called persistent trigeminal artery variant. The PICA also can arise from the cervical segment of the ICA, and it enters the posterior fossa via the hypoglossal canal, where it is called persistent hypoglossal artery variant. Using magnetic resonance angiography (MRA), we diagnosed a 79-year-old man with a PICA arising from the ascending pharyngeal artery and passing through the medial side of the jugular foremen pars vascularis. Only six cases of this variation have been reported previously in the English language literature. To identify this variation on MRA, the careful observation of source images is useful. Recognizing this variation is important in order to avoid ischemic cerebellar complications during neck surgery and endovascular therapy.

Medial type persistent trigeminal artery associated with a saccular aneurysm at its trunk.

There are four types of fetal anastomosis between the carotid and vertebrobasilar arteries at 5 weeks gestation; from caudal to cranial position, these involve the proatlantal intersegmental, hypoglossal, otic, and trigeminal arteries. Excluding otic artery, these arteries may persist rarely. Persistent trigeminal artery (PTA) is the most common carotid-vertebrobasilar anastomosis, and the medial type (intrasellar) PTA is quite rare, accounting for approximately 10% of all PTA cases. An aneurysm is occasionally found at the origin of the PTA. Rarely, an aneurysm arises at the trunk of the PTA. Using magnetic resonance angiography, we identified a case of medial type PTA with an unruptured saccular aneurysm at its trunk.

Angiographic Characterization of the External Carotid Artery: Special Attention to Variations in Branching Patterns.

Knowledge of branching patterns of external carotid artery (ECA) is essential for planning and execution of head and neck surgeries. Digital subtraction angiography (DSA) images of 532 ECAs from 302 consecutive patients were retrospectively evaluated. We classify the branch variants of ECA into three types, simply based on the number of branches arising close together. Type A, Type B, and Type C variants are defined as two, three, and four or more branches of ECAs arising at a common point from the proximal ECA, respectively. In this classification, the distal ECA was counted as one branch. Of 532 ECAs, Type A was found in 344 ECAs (64.6%) of 237 patients (78.5%), Type B in 134 ECAs (25.2%) of 110 patients (36.4%), and Type C in 54 ECAs (10.2%) of 49 patients (16.2%). The distance from the common carotid artery (CCA) bifurcation to the first branch of ECA with Type C was 14.7 ± 6.6 mm; its distance is shorter compared with Type A (21.8 ± 15.6 mm) and Type B (20.6 ± 8.9 mm) (P < 0.05). The position of CCA bifurcation with Type C was detected at the third-fourth junction cervical vertebral level or higher in 52 of 54 ECAs (96.3%), significantly higher than those of the other types (P < 0.05). In conclusion, Type C ECA has aggregated vessels with short distance from CCA and high position of CCA bifurcation. Type C ECA is not uncommon; thus, special consideration should be paid to avoid complications during surgeries.

Intraoperative monitoring of cerebral cortical blood flow and middle cerebral artery pressure as a substitute for preoperative balloon test occlusion in patients with internal carotid artery aneurysms.

BACKGROUND: Balloon test occlusion (BTO) is a useful examination to evaluate the indications and methods for revascularization when treating unclippable internal carotid artery (ICA) aneurysms by parent artery occlusion. The purpose of the present study was to investigate the relationship between intraoperative monitoring of cerebral cortical blood flow (CoBF) and middle cerebral artery (MCA) pressure during surgical parent artery occlusion and the findings of BTO. METHODS: Eleven patients with an ICA aneurysm in the cavernous portion underwent preoperative BTO with brain perfusion single-photon emission tomography. CoBF was monitored intraoperatively in all patients using a laser Doppler probe. The lowest CoBF during test occlusion of the ICA under functioning superficial temporal artery-middle cerebral artery (STA-MCA) bypass was determined, and the ratio of the value to the CoBF immediately before test occlusion of the ICA was calculated in the frontal and temporal lobes. When the CoBF ratio in the frontal or temporal lobe was less than 0.9, high-flow bypass grafting was added. The MCA pressure was also measured by temporarily occluding the proximal STA. RESULTS: Of the 11 patients undergoing STA-MCA bypass, 5 patients underwent concomitant high-flow bypass grafting. Significant differences in the cerebrovascular reserve based on SPECT during BTO, CoBF, and the MCA pressure ratio during surgery were observed when comparing the two groups. CONCLUSIONS: Intraoperative monitoring of CoBF and MCA pressure may be useful, along with preoperative BTO, for patients with unclippable ICA aneurysms.

Two Cases of Mechanical Thrombectomy in Patients with Fenestration of the M1 Segment of the Middle Cerebral Artery.

M1 fenestration of the middle cerebral artery is rare. We present two patterns of acute thromboembolic conditions in M1 fenestrations treated with mechanical thrombectomy. Case 1 was a male in his 60s presenting with right hemiparesis and aphasia. Angiography showed acute left M1 proximal occlusion; the first direct aspiration revealed two parallel routes, and the second aspiration achieved complete recanalization of the left M1 fenestration. Case 2 was a male in his 70s presenting right hemiparesis and aphasia. Angiography revealed a sudden stair-like narrowing of the left M1 in the intermediate part, and a retrograde blood flow cavity was observed on the upper side of the distal part. Mechanical thrombectomy was performed to diagnose the upper limb occlusion of the left M1 fenestration, and successful recanalization was achieved through direct aspiration. Anatomical variations, such as fenestration, should be considered to reduce complication risks.

Effect of cilostazol in the treatment of acute ischemic stroke in the lenticulostriate artery territory.

BACKGROUND: Cilostazol, an inhibitor of phosphodiesterase 3, has various pleiotropic effects besides its antiplatelet activity. This study examined the efficacy of cilostazol for the treatment of acute perforating artery infarction. METHODS: In this prospective, randomized, open-label, blinded-end point trial, 100 patients with cerebral infarction in the territory of the lenticulostriate arteries were enrolled within 48 h of onset. Patients were randomly treated with both cilostazol and ozagrel for 14 days (n = 50, cilostazol group) or ozagrel alone for 14 days (n = 50, control group). The primary end point was the proportion of favorable outcomes 30 days after randomization as defined by a modified Rankin Scale (mRS) score of 0-2. Secondary end points included the incidence of neurological deterioration (an increase of ≥ 2 on the National Institutes of Health Stroke Scale within 7 days). RESULTS: Favorable outcomes (mRS scores 0-2) were similar in both groups (81.3 and 82.0% in the cilostazol and control groups, respectively). The incidence of neurological deterioration was lower in the cilostazol group than the control group (12.5 and 16.0%, respectively) with a 21.9% relative risk reduction, although the difference was not statistically significant. CONCLUSIONS: Cilostazol did not prevent the neurological deterioration of perforating artery infarction.

Endovascular Treatment for Acute Ischaemic Stroke Caused by Vertebral Artery Dissection: A Report of Three Cases and Literature Review.

Vertebrobasilar artery dissection is an uncommon cause of acute ischaemic stroke (AIS). Optimal endovascular management has not been established. This study aimed to share our experience with endovascular reperfusion therapy for vertebrobasilar artery occlusion due to vertebral artery dissection (VAD). We retrospectively reviewed 134 consecutive patients with AIS who received urgent endovascular reperfusion therapy between November 2017 and November 2019. Three patients diagnosed with VAD were investigated. The evaluation included mechanisms of vertebrobasilar artery occlusion due to VAD, variations in endovascular procedures, and functional outcomes. Dissections at the V3, V4 and extension of V3 to V4 segments were seen in one patient each. The mechanism of AIS was different in each patient: occlusion of the distal non-dissected artery due to an embolus from the dissection site (distal occlusion), haemodynamic collapse of the entire vertebrobasilar artery system due to the arterial dissection itself (local occlusion), or coexistence of distal occlusion and local occlusion (tandem occlusion). The endovascular reperfusion therapy was performed corresponding to the abovementioned mechanisms: mechanical thrombectomy for distal occlusion, stenting for local occlusion, and a combination of thrombectomy and stenting for tandem occlusion. In all three patients, effective recanalization and functional independence (modified Rankin Scale scores of 0-2 at 90 days after the onset) were achieved. Endovascular treatment corresponding to the individual mechanism of AIS may improve patient outcomes.

Visual disorders caused by cranial arteriovenous fistula with venous drainage into the superior ophthalmic vein.

BACKGROUND: Although the abnormal venous drainage into the superior ophthalmic vein (SOV) is a well-known entity responsible for ocular symptoms, it remains unclear to what degree it affects the visual function. The purpose of this study was to evaluate the incidence, characteristics and outcomes of the visual disorders in patients with intracranial arteriovenous fistula (AVF) with venous drainage into the SOV. METHODS: This retrospective study involved eight patients diagnosed with intracranial AVFs with abnormal venous drainage into the SOV between January 2014 and December 2016. RESULTS: The most common location of AVF was the cavernous sinus (CS) in five patients, followed by the intraorbit in two patients and superior sagittal sinus (SSS) in one patient. Visual disorders were detected in three patients (two intraorbit and one CS). The visual field contraction was observed in a patient with intraorbital AVF, and the reduction of visual acuity was confirmed in another patient with intraorbital AVF and a patient with CS dural AVF. All patients underwent an interventional treatment consisting of endovascular embolisation, stereotactic radiosurgery or both, which was selected based on their angioarchitecture. Although angiographic cure of AVF was confirmed in all patients, visual function did not fully recover in two patients with intraorbital AVF. CONCLUSIONS: In cases of intraorbital AVF, visual disorders are more frequent and can result in poorer outcomes compared with other dural AVFs with drainage into the SOV. Early diagnosis and treatment are crucial to preserve the visual function of patients with intraorbital AVF.

Iatrogenic Extravasation and Extracranial ICA Dissection during Neurointervention Evaluated by Transoral Carotid Ultrasonography: Case Report.

We described an 88-year-old woman presented with large aneurysm on the carotid siphon of the right internal carotid artery (ICA). Digital subtraction angiography showed extravasation from the distal cervical segment of the right ICA due to positioning a guiding catheter for intra-aneurysmal coil embolization. Transoral carotid ultrasonography (TOCU) showed arrested bleeding and a pseudolumen in the distal cervical segment of the right ICA. We originally described that TOCU was useful for evaluating iatrogenic extravasation and extracranial ICA dissection during neurointervention.

Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations.

OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.

Cervical perimedullary arteriovenous shunts: a study of 22 consecutive cases with a focus on angioarchitecture and surgical approaches.

BACKGROUND: Reports of cervical perimedullary arteriovenous shunt (PMAVS) are limited, and treatment strategies have not been established. OBJECTIVE: To describe angioarchitecture and optimal treatment strategies for cervical PMAVS. METHODS: We treated 22 patients with cervical PMAVS between 2000 and 2012 (8 women and 14 men; age, 9-80 years). According to the classification, our patients included type IVa (4 patients), type IVb (16 patients), and type IVc (2 patients). Seventeen patients presented with subarachnoid hemorrhage. RESULTS: A total of 41 shunting points were localized in 22 patients, of which 34 points were located ventral or ventrolateral to the spinal cord. The anterior spinal artery (ASA) contributed to the shunts in 16 patients. Aneurysm formation was identified in 8 patients. Endovascular treatment was attempted in 3 patients, resulting in complete obliteration in 1 patient (type IVc). Overall, 21 patients underwent open surgery. An anterior approach with corpectomy was elected for 2 patients; the other 19 patients underwent the posterior approaches using indocyanine green videoangiography, intraoperative angiography, endoscopy (8 patients), and neuromonitoring. Twenty patients were rated as having a good recovery at 6 months after surgery. No recurrence was observed in any patients during the follow-up (mean, 59.7 months). CONCLUSION: Shunting points of the cervical PMAVS were predominantly located ventral or ventrolateral to the spinal cord and were often fed by the ASA. Even for ventral lesions, posterior exposure assisted with neuromonitoring and endoscopy, and intraoperative angiography provided a view sufficient to understand the relationships between the shunts and the ASA and contributed to good surgical outcomes.

Endovascular embolization of cerebral arteriovenous malformations: results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2.

This retrospective study constitutes a part of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Its purpose is to evaluate the feasibility, safety, and outcome of endovascular embolization for cerebral arteriovenous malformations (AVMs) in Japan. Nine hundred and eighty-seven embolization procedures were registered with JR-NET 1 and 2 (424 procedures in 122 institutions with JRNET 1 and 563 procedures in 150 institutions with JRNET 2). In total, 790 patients (80.1%) had favourable clinical outcomes defined as modified Rankin Scale (mRS) scores 0-2 at 30 days after embolization. Complete AVM obliteration by embolization alone was achieved in 90 procedures (9.1%). The procedural morbidity and mortality rate was 2.5% and 0.3% per procedure, respectively. In the multivariate logistic regression models, deep venous drainage and embolization of four or more feeding pedicles per session were significantly associated with any treatment-related complications (P = 0.02 and P = 0.003, respectively). About 6 cm or more in maximum nidus diameter had a negative correlation with complications (P = 0.003). Our study shows that embolization of cerebral AVMs was performed with a high degree of safety and a low rate of symptomatic complications in Japan.

Endovascular Embolization of Cerebral Arteriovenous Malformations: Results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2.

This retrospective study constitutes a part of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Its purpose is to evaluate the feasibility, safety, and outcome of endovascular embolization for cerebral arteriovenous malformations (AVMs) in Japan. Nine hundred and eighty-seven embolization procedures were registered with JR-NET 1 and 2 (424 procedures in 122 institutions with JRNET 1 and 563 procedures in 150 institutions with JRNET 2). In total, 790 patients (80.1%) had favourable clinical outcomes defined as modified Rankin Scale (mRS) scores 0­2 at 30 days after embolization. Complete AVM obliteration by embolization alone was achieved in 90 procedures (9.1%). The procedural morbidity and mortality rate was 2.5% and 0.3% per procedure, respectively. In the multivariate logistic regression models, deep venous drainage and embolization of four or more feeding pedicles per session were significantly associated with any treatment-related complications (P=0.02 and P=0.003, respectively). About 6 cm or more in maximum nidus diameter had a negative correlation with complications (P=0.003). Our study shows that embolization of cerebral AVMs was performed with a high degree of safety and a low rate of symptomatic complications in Japan.

Endovascular Embolization of Cerebral Arteriovenous Malformations: Results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2.

This retrospective study constitutes a part of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. Its purpose is to evaluate the feasibility, safety, and outcome of endovascular embolization for cerebral arteriovenous malformations (AVMs) in Japan. Nine hundred and eighty-seven embolization procedures were registered with JR-NET 1 and 2 (424 procedures in 122 institutions with JRNET 1 and 563 procedures in 150 institutions with JRNET 2). In total, 790 patients (80.1%) had favourable clinical outcomes defined as modified Rankin Scale (mRS) scores 0­2 at 30 days after embolization. Complete AVM obliteration by embolization alone was achieved in 90 procedures (9.1%). The procedural morbidity and mortality rate was 2.5% and 0.3% per procedure, respectively. In the multivariate logistic regression models, deep venous drainage and embolization of four or more feeding pedicles per session were significantly associated with any treatment-related complications (P=0.02 and P=0.003, respectively). About 6 cm or more in maximum nidus diameter had a negative correlation with complications (P=0.003). Our study shows that embolization of cerebral AVMs was performed with a high degree of safety and a low rate of symptomatic complications in Japan.

Angiographic circulation time and cerebral blood flow during balloon test occlusion of the internal carotid artery.

Angiography-based balloon test occlusion (BTO) has been empirically used to predict tolerance to permanent carotid artery occlusion. We tested the hypothesis that the laterality of the hemispheric circulation time (HCT) of the contrast medium at cerebral angiography would reflect bilateral asymmetry of the cerebral blood flow (CBF) during BTO. Thirty-one consecutive patients who underwent BTO of the internal carotid artery were retrospectively analyzed. HCT was defined as the interval between the time-to-peak in the middle cerebral artery and the cortical veins calculated using time-density curve. The difference in HCT between the occluded and nonoccluded side was calculated at the carotid or dominant vertebral angiograms obtained during BTO. We estimated the correlation between the difference in HCT and bilateral asymmetry of the CBF, which was quantitatively determined by single-photon emission computed tomography. The HCT was 5.3±1.5 seconds and regional CBF was 41.3±11.3 mL/100 g per minute in the occluded side, compared with 3.6±0.9 seconds and 48.4±14.9 mL/100 g per minute in the nonoccluded side, respectively. The difference in HCT was strongly correlated with the asymmetry ratio of the CBF (r(2)=0.89, P<0.0001). Angiographically based measurement of the cerebral circulation time can provide valuable information concerning cerebral hemodynamics.

Medullary infarction as a poor prognostic factor after internal coil trapping of a ruptured vertebral artery dissection.

OBJECT: Internal coil trapping is a treatment method used to prevent rebleeding from a ruptured intracranial vertebral artery dissection (VAD). Postoperative medullary infarctions have been reported as a complication of this treatment strategy. The aim of this study was to determine the relationship between a postoperative medullary infarction and the clinical outcomes for patients with ruptured VADs treated with internal coil trapping during the acute stage of a subarachnoid hemorrhage (SAH). METHODS: A retrospective study identified 38 patients who presented between 2006 and 2011 with ruptured VADs and underwent internal coil trapping during the acute stage of SAH. The SAH was identified on CT scanning, and the diagnosis for VAD was rendered by cerebral angiography. Under general anesthesia, the dissection was packed with coils, beginning at the distal end and proceeding proximally. When VAD involved the origin of the posterior inferior cerebellar artery (PICA) with a large cerebellar territory, an occipital artery (OA)-PICA anastomosis was created prior to internal coil trapping. The pre- and postoperative radiological findings, clinical course, and outcomes were analyzed. RESULTS: The internal coil trapping was completed within 24 hours after admission. An OA-PICA anastomosis followed by internal coil trapping was performed in 5 patients. Postoperative rebleeding did not occur in any patient during a mean follow-up period of 16 months. The postoperative MRI studies showed medullary infarctions in 18 patients (47%). The mean length of the trapped VAD for the infarction group (15.7 ± 6.0 mm) was significantly longer than that of the noninfarction group (11.5 ± 4.3 mm) (p = 0.019). Three of the 5 patients treated with OA-PICA anastomosis had postoperative medullary infarction. The clinical outcomes at 6 months were favorable (modified Rankin Scale Scores 0-2) for 23 patients (60.5%) and unfavorable (modified Rankin Scale Scores 3-6) for 15 patients (39.5%). Of the 18 patients with postoperative medullary infarctions, the outcomes were favorable for 6 patients (33.3%) and unfavorable for 12 patients (66.7%). A logistic regression analysis predicted the following independent risk factors for unfavorable outcomes: postoperative medullary infarctions (OR 21.287 [95% CI 2.622-498.242], p = 0.003); preoperative rebleeding episodes (OR 7.450 [95% CI 1.140-71.138], p = 0.036); and a history of diabetes mellitus (OR 45.456 [95% CI 1.993-5287.595], p = 0.013). CONCLUSIONS: A postoperative medullary infarction was associated with unfavorable outcomes after internal coil trapping for ruptured VADs. Coil occlusion of the long segment of the VA led to medullary infarction, and an OA-PICA bypass did not prevent medullary infarction. A VA-sparing procedure, such as flow diversion by stenting, is an alternative treatment in the future, if this approach is demonstrated to effectively prevent rebleeding.

Antiplatelet therapy for prevention of thromboembolic complications associated with coil embolization of unruptured cerebral aneurysms.

BACKGROUND: Antiplatelet agents are used during endovascular treatment of cerebral aneurysms to prevent thromboembolic complications. OBJECTIVE: The aim of this study was to investigate the efficacy of clopidogrel for the prevention of thromboembolic complications during elective coil embolization of unruptured cerebral aneurysms. METHODS: Sixty-three patients prospectively received oral clopidogrel 75 mg/day from 3 days before and for 1 day after the procedure at our institute (Kohnan Hospital, Sendai, Japan) during 2007. RESULTS: At 24 hours post-coiling, significantly less high-intensity areas, detected by MRI with diffusion-weighted imaging (MRI-DWI), were observed in clopidogrel-treated patients compared with a historical control cohort of aspirin (acetylsalicylic acid)-treated patients (13/63 [20.6%] vs 27/69 [39.1%]; p = 0.02), primarily due to a statistically significantly lower rate during repair of small (<10 mm) lesions (p = 0.008). Also, the rate of periprocedural thromboembolic events was lower in the clopidogrel than the aspirin cohort (2/63 [3.2%] vs 5/69 [7.2%]; p = 0.3). CONCLUSIONS: Clopidogrel was generally well tolerated with no signs of hemorrhagic complications or liver dysfunction.

Intraorbital arteriovenous malformation treated by transarterial embolization: technical case report.

BACKGROUND AND IMPORTANCE: Intraorbital arteriovenous malformations (AVMs) are rare, and their clinical management is controversial. A case of orbital AVM successfully treated by transarterial embolization with diluted glue is reported. CLINICAL PRESENTATION: A 53-year-old man developed a left pulsating exophthalmos, chemosis, and ocular pain, revealing the presence of a left intraorbital AVM. A microcatheter was selectively placed into the feeders arising from the left ophthalmic artery. Diluted glue was injected toward the nidus through the microcatheter, with monitoring by digital subtraction angiogram. These procedures were performed for 2 individual proper feeders. Superselective angiography for the central retinal artery was also performed instead of a retinal Wada test. His orbital symptoms improved immediately after the procedure without further visual disturbance. Follow-up digital subtraction angiogram revealed the disappearance of the AVM. CONCLUSION: Transarterial embolization can be considered one of the radical treatments for orbital AVMs.