Cirrhosis-associated intracranial shunting lesions: illustrative case

BACKGROUND: A cerebral arteriovenous malformation (AVM) is a vascular lesion classically regarded as congenital, in which arteries and veins connect directly without an intervening capillary bed, forming a nidus of fragile, rupture-prone vasculature. Emerging reports of de novo cerebral arteriovenous shunting raise the possibility that some lesions are acquired, or that these cases represent a broader category of dynamic shunting lesions. In the setting of cirrhosis, a review of the literature identified 8 reported cases of acquired intracranial arteriovenous shunting lesions, 2 of which resolved after liver transplantation. OBSERVATIONS: The authors report the case of a 59-year-old woman with alcoholic cirrhosis who presented with altered mental status and an intraparenchymal hemorrhage. Digital subtraction angiography demonstrated multifocal intracranial shunting lesions that were not present on prior neuroimaging, supporting interval development in association with progression of liver disease. LESSONS: Cirrhosis-associated metabolic, hemodynamic, and endothelial derangements may promote aberrant cerebrovascular remodeling and focal arteriovenous shunting that can mimic an AVM phenotype. The authors call these lesions cirrhosis-associated intracranial shunting lesions and propose they represent a distinct, potentially dynamic entity that may regress with treatment of the underlying hepatic dysfunction, including liver transplantation. https://thejns.org/doi/10.3171/CASE25824.