Background Hemorrhage is a major complication of brain arteriovenous malformations (AVMs) embolization, which can be related to persistent arteriovenous shunts that were not completely occluded during the embolization. In transvenous embolization (TVE) this risk is deemed higher for AVMs larger than 3 cm featuring multiple veins of drainage. Herein, we will discuss a few selected cases where brain AVMs with more than one draining vein were deemed safe for curative embolization with advanced endovascular techniques after a careful anatomical study through the four dimensional-digital subtraction angiography (4D-DSA) imaging.

Methods Four brain AVMs with more than one draining vein were selected from our database. A curative embolization through advanced endovascular techniques with curative intent was planned with the 4D-DSA. Immediate and 6 month angiographic controls are provided, as well as post-procedure MRI.

Results All 4 cases were successfully embolized, with stable 6 month angiographic controls. Although multiple draining veins were present, the 4D-DSA allowed the identification of favorable venous anatomy, such as a connection point between draining veins in case 1, as well as a main draining vein in cases 2 and 3. Case four is an exception to this, and although the AVM was cured patient presented asymptomatic ischemia after treatment. The anatomical insights gained through 4D-DSA imaging and the advanced endovascular techniques employed are discussed in detail.

Conclusion Brain AVMs with multiple draining veins may behave like featuring a single draining vein, which can be identified through a careful anatomical study in the 4D-DSA, highlighting its importance for a safe endovascular treatment.