Timing of Diffusion Tensor Imaging in the Management of a Ruptured Pediatric Arteriovenous Malformation: Illustrative Case

Diffusion tensor imaging (DTI) can characterize eloquent white matter tracts affected by brain arteriovenous malformations (AVMs). However, DTI interpretation can be difficult in ruptured cases due to the presence of blood products. The authors present the case of a ruptured pediatric AVM in the corticospinal tract (CST) and discuss how DTI at different time points informed the treatment. A 9-year-old female presented with a sudden headache and left hemiparesis. She was found to have a Spetzler-Martin grade III, Supplementary grade I AVM in the right caudate and centrum semiovale, with obliteration and corresponding reduced fractional anisotropy (FA), fiber density (FD), and tract count (TC) of the adjacent CST on DTI. The patient remained stable and was scheduled for elective resection following a 6-week period to facilitate hematoma resorption. After 6 weeks, repeat DTI showed part of the nidus within intact CST fibers with concordant improvement in FA, FD, and TC. Considering the nidus location, CST integrity, and motor function recovery, surgery was deferred in favor of stereotactic radiosurgery. In ruptured AVMs, DTI may initially create an incomplete picture and false assumptions about white matter tract integrity. DTI should be repeated if delayed treatment is appropriate to ensure informed decision-making and prevent avoidable permanent neurological deficits. https://thejns.org/doi/10.3171/CASE24225