The Coexistence of Anaplastic Astrocytomas and Arteriovenous Malformation

Case Report

Ann Carcinog. 2017; 2(1): 1010.

The Coexistence of Anaplastic Astrocytomas and Arteriovenous Malformation

Oommen A¹, Govindan J² and Abdul Jalal MJ³*

¹Department of Neurosurgery, VPS Lakeshore Hospital, India

²Department of Pathology, VPS Lakeshore Hospital, India

³Department of Rheumatology and Internal Medicine, VPS Lakeshore Hospital, India

*Corresponding author: Muhammed Jasim Abdul Jalal, Senior Registrar, Department of Rheumatology and Internal Medicine, VPS Lakeshore Hospital, Nettoor .P.O. Maradu, NH 47 – Byepass, Ernakulam, Kerala, India

Received: May 05, 2017; Accepted: June 07, 2017; Published: June 15, 2017


Coexistence of astrocytoma with cerebral vascular malformations is unusual, especially if both lesions occur separately. Pre-operative Angiogram will help us to identify any co-existing Arteriovenous Malformation (AVM). This will in turn change the treatment strategy for astrocytoma. Pre-operative embolisation for AVM may be done prior to the glioma excision. There is increased risk of bleeding if AVMs are not pre-operatively diagnosed. AVMs co-existing with astrocytomas are rare. We report a case of anaplastic astrocytoma coexisting with an acquired arteriovenous malformation.

Keywords: Anaplastic astrocytoma; Arteriovenous malformations; Acquired AVM; De novo AVM; VEGF


An Arteriovenous Malformation (AVM) is a vascular malformation characterized by arteriovenous shunt through a collection of tortuous vessels without an intervening capillary bed. The most common clinical presentation of AVM is headache and seizures. About 15% can be asymptomatic. More than 50% of AVMs present with intracranial hemorrhages. This contributes to about 2% of all hemorrhagic strokes each year. AVM can be treated either by endovascular embolisation, neurosurgery or radiation therapy [1].

The exact causes of AVMs are still unclear. Apart from congenital AVMs, there are theories suggesting various dynamic developmental processes promoting the existence of acquired AVMs. Vascular Endothelial Growth Factors (VEGF) and Transforming Growth Factors (TGF) play a crucial role in the angiogenesis leading to the development of AVMs, thus challenging the theory of congenital occurrence of all cerebral AVMs.

Anaplastic astrocytomas are WHO grade III gliomas. Anaplastic astrocytoma and glioblastoma are estimated to affect 5-8 people per 100,000 in the general population [2]. Anaplastic astrocytomas are more common in adults than children. In adults, anaplastic astrocytomas commonly develop between 30 to 50 years [2].

Grossly anaplastic astrocytomas are Ill-defined with blurred margins. They may have spongy or gelatinous appearance, with micro cysts and calcifications. They may have a clearer distinction from surrounding brain structures than low grade diffuse astrocytomas. Microscopically, they are similar to grade II tumors but more cellular, more atypia, and mitoses are seen. By definition, vascular proliferation and necrosis are absent.

Coexistence of astrocytoma with cerebral vascular malformations is unusual, especially if both such lesions occur as separate part in the brain [3]. Rare coincidences are reported involving mostly gliomas and meningiomas.

Case Report

A 45-year-old male presented with headache and blurring of vision in the right eye of 2 weeks duration. The patient did not have any episodes of seizures, double vision or loss of consciousness. There was no significant past illness. He was conscious and oriented with a GCS of 15/15 [E4V5M6]. He had nominal aphasia. The pupils were equal and reactive to light. There were no gross motor deficits except for a right sided pronator drift. All the DTRs were normal. The plantar responses were flexor bilaterally. He did not have any cerebellar/meningeal signs. Systemic examinations were normal.

Ophthalmological evaluation showed visual acuity of 6/12 in both eyes. Eye movements were equal in all directions. There was no nystagmus. He had normal color vision. Visual field evaluation showed marked deterioration of peripheral field. Fundus examination was normal under mydriasis with short acting mydriatics.


MRI brain Axial T2, FLAIR, SWI, DWI coronal FLAIR and sagittal T1W; dynamic MR perfusion imaging; post contrast axial and coronal T1FS, sag 3D MPRAGE and multivoxel MR spectroscopy were performed.

A large 7.1 x 6.0 x 5.3 cm (AP x Transverse x CC) necrotic, non diffusion restricting, left temporoparietal mass with thick irregular enhancing ring was seen. Dynamic MR Perfusion study showed elevated Cerebral Blood Volume (CBV) in the periphery with relative Cerebral Blood Volume (r CBV) up to 16.3. Multivoxel MR Spectroscopy showed elevated choline and reduced NAA in the solid tumor component. Central necrotic core showed elevated lipid/ lactate peak. There was mild elevation of choline and reduction in NAA in peritumoral white matter. Intra lesional foci of hemorrhage were seen demonstrating susceptibility on SW images in tumor rim (Figure 1).

Citation: Oommen A, Govindan J and Abdul Jalal MJ. The Coexistence of Anaplastic Astrocytomas and Arteriovenous Malformation. Ann Carcinog. 2017; 2(1): 1010.