The management of patients with arteriovenous malformations and associated intracranial aneurysms.

OBJECTIVE Few published studies have focused specifically on the unique management issues encountered in treating patients with arteriovenous malformations (AVMs) and associated intracranial aneurysms. The primary objective of this study was to retrospectively review the clinical and radiographic features of these patients. METHODS Medical records of all patients seen at Stanford University Hospital between 1988 and 1996 with a diagnosis of AVMs were retrospectively reviewed. Aneurysms were identified by conventional angiography and characterized by size, number, and location relative to the AVMs. AVMs were graded according to the Spetzler-Martin scale. Odds ratios were calculated for the risk of intracranial hemorrhage. Variables included age, sex, number of aneurysms, and AVM grade. RESULTS Forty-five of 600 patients (7.5%) were identified as having coexisting intracranial aneurysms. All 45 patients had high-flow malformations, and 58% had AVMs of Spetzler-Martin Grade IV or higher. A majority of patients had multiple aneurysms. There was a statistically significant increase in AVM hemorrhage in female patients (odds ratio, 8.53 [1.87-38.98]; P < 0.005). There was no statistically significant correlation between the development of hemorrhage and either age, AVM grade, or the number of aneurysms. Twenty-three patients (51%) presented with intracranial hemorrhage: bleeding occurred from the AVMs in 15 and from ruptured aneurysms in 5, and the source of the bleeding could not be determined in 3. Overall, nine patients (20%) bled from ruptured aneurysms: five at presentation, two during or within 3 weeks of AVM treatment, and two from new aneurysms. Two of these nine patients died as a direct result of aneurysmal subarachnoid hemorrhage. Five patients (11%) developed new aneurysms. CONCLUSION Aneurysms associated with AVMs are at risk for rupture before, during, and immediately after treatment of the AVMs. New aneurysms may arise in patients with high-flow AVMs. The risk of intracranial hemorrhage from either source is higher in female patients. To reduce the complications of intracranial hemorrhage in these patients, we recommend a management protocol designed to treat the aneurysms by surgical or endovascular means before administering definitive therapy for the AVMs. Meticulous intraoperative blood pressure control and fluid management during aneurysm surgery is critical to avoid hemorrhage from the AVMs.

[1]  K. Matsumoto,et al.  Rupture of a cerebral aneurysm during embolization for a cerebral arteriovenous malformation. , 1995, AJNR. American journal of neuroradiology.

[2]  J W Sayre,et al.  Aneurysms related to cerebral arteriovenous malformations: superselective angiographic assessment in 58 patients. , 1994, AJNR. American journal of neuroradiology.

[3]  V. McDermott,et al.  Superior cerebellar artery aneurysms associated with infratentorial arteriovenous malformations. , 1994, Clinical imaging.

[4]  J. Tew,et al.  Feeding artery pedicle aneurysms: association with parenchymal hemorrhage and arteriovenous malformation in the brain. , 1994, Journal of neurosurgery.

[5]  M. Cossu,et al.  Association of aneurysm and arteriovenous malformation on the posterior inferior cerebellar artery. Report of three further cases and review of the literature. , 1994, Acta neurologica.

[6]  R. A. Solomon,et al.  The treatment of associated intracranial aneurysms and arteriovenous malformations. , 1992, Journal of neurosurgery.

[7]  S. Mabuchi,et al.  Distal aneurysms of the superior cerebellar artery and posterior inferior cerebellar artery feeding an associated arteriovenous malformation: case report. , 1992, Neurosurgery.

[8]  P. Gutin,et al.  Multiple arterial fenestrations, multiple aneurysms, and an arteriovenous malformation in a patient with subarachnoid hemorrhage. , 1991, Surgical neurology.

[9]  G. Forbes,et al.  Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions. , 1990, Journal of neurosurgery.

[10]  M. Marks,et al.  Hemorrhage in intracerebral arteriovenous malformations: angiographic determinants. , 1990, Radiology.

[11]  D. Kondziolka,et al.  Cerebral Arteriovenous Malformations with Associated Arterial Aneurysms: Hemodynamic and Therapeutic Considerations , 1988, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques.

[12]  C. Azzam.  Growth of multiple peripheral high flow aneurysms of the posterior inferior cerebellar artery associated with a cerebellar arteriovenous malformation. , 1987, Neurosurgery.

[13]  J. Brotchi,et al.  Arteriovenous malformation associated with multiple aneurysms in the posterior fossa: a case report with a review of the literature. , 1987, Neurosurgery.

[14]  J. Wisoff,et al.  Aneurysms of the distal anterior cerebral artery and associated vascular anomalies. , 1987, Neurosurgery.

[15]  J. Brick,et al.  Cerebral arteriovenous malformation coexistent with intracranial aneurysm and persistent trigeminal artery. , 1987, Southern medical journal.

[16]  H. Batjer,et al.  Intracranial arteriovenous malformations associated with aneurysms. , 1986, Neurosurgery.

[17]  R F Spetzler,et al.  A proposed grading system for arteriovenous malformations. , 1986, Journal of neurosurgery.

[18]  L. Carter,et al.  Multiple unusual aneurysms and arteriovenous malformation in a single patient: a case report. , 1985, Neurosurgery.

[19]  T. Kojima,et al.  Posterior inferior cerebellar artery aneurysm associated with arteriovenous malformation fed by the same artery. , 1985, Surgical neurology.

[20]  R. Wilkins.  Natural History of Intracranial Vascular Malformations: A Review , 1985, Neurosurgery.

[21]  H. Handa,et al.  Location of intracranial aneurysms associated with cerebral arteriovenous malformation: statistical analysis. , 1984, Surgical neurology.

[22]  J. Østergaard.  Association of Intracranial Aneurysm and Arteriovenous Malformation in Childhood , 1984 .

[23]  T. Itakura,et al.  [Significance of hemodynamic stress on the development of intracranial aneurysms. - Analysis of the cases of coexisting intracranial aneurysm and arteriovenous malformation of the brain (author's transl)]. , 1982, Neurologia medico-chirurgica.

[24]  S. Wolpert,et al.  The association of cerebral aneurysms, infundibula, and intracranial arteriovenous malformations. , 1982, Stroke.

[25]  T. Itakura,et al.  The association of intracranial aneurysms and arteriovenous malformation of the brain. Case report. , 1981, Journal of neurosurgery.

[26]  H. Rizzoli,et al.  Coexisting intracranial aneurysm and arteriovenous malformation: case report. , 1981, Neurosurgery.

[27]  F. Tovaryš,et al.  [A case of arteriovenous malformation, grade IV, with two giant aneurysms in dominant side speech and motor-senosry area--evaluation of grades, operability with microsurgical technique and pre- and post-operative performance status in 37 cases of cerebral vascular malformation (author's transl)]. , 1980, No shinkei geka. Neurological surgery.

[28]  M. Hatano,et al.  Coexistence of posterior inferior cerebellar artery aneurysm and arteriovenous malformation fed by the same artery. , 1979, Surgical neurology.

[29]  J. Suzuki,et al.  Intracranial aneurysms associated with arteriovenous malformations. , 1979, Journal of neurosurgery.

[30]  H. Nornes,et al.  Intraoperative evaluation of cerebral hemodynamics using directional Doppler technique. Part 1: Arteriovenous malformations. , 1979, Journal of neurosurgery.

[31]  J. Chambers,et al.  Giant thrombosed aneurysm associated with an arteriovenous malformation. Case report. , 1978, Journal of neurosurgery.

[32]  J. Suzuki,et al.  [Intracranial aneurysm associated with arteriovenous malformation (author's transl)]. , 1977, No shinkei geka. Neurological surgery.

[33]  M. Kagawa,et al.  [A case of multiple anomalies of cerebral vessels--fenestration of the middle cerebral artery aneurysm of the anterior communicating artery and arteriovenous malformation on the frontopolar region (author's transl)]. , 1977, No shinkei geka. Neurological surgery.

[34]  N. Miyazawa,et al.  Multiple intracranial aneurysms and vascular malformations in an infant. Case report. , 1972, Journal of neurosurgery.

[35]  H. Shenkin,et al.  Arteriovenous anomaly of the brain associated with cerebral aneurysm. Case report. , 1971, Journal of neurosurgery.

[36]  Stehbens We.  Blood vessel changes in chronic experimental arteriovenous fistulas. , 1968 .

[37]  D. L. Fry.  Acute Vascular Endothelial Changes Associated with Increased Blood Velocity Gradients , 1968, Circulation research.

[38]  G. Perret,et al.  Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section VI. Arteriovenous malformations. An analysis of 545 cases of cranio-cerebral arteriovenous malformations and fistulae reported to the cooperative study. , 1966, Journal of neurosurgery.

[39]  H. Locksley,et al.  Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. , 1966, Journal of neurosurgery.

[40]  H. Locksley.  SECTION V, PART I: Natural History of Subarachnoid Hemorrhage, Intracranial Aneurysms and Arteriovenous Malformations* , 1966 .

[41]  S. Cronqvist,et al.  INTRACRANIAL ARTERIOVENOUS MALFORMATION AND ARTERIAL ANEURYSM IN THE SAME PATIENT , 1966 .

[42]  G. Nicola,et al.  Simultaneous occurrence of multiple intracranial aneurysms and angioma. Presentation of a case. , 1966, Psychiatria et neurologia.

[43]  M. R. Roach,et al.  CHANGES IN ARTERIAL DISTENSIBILITY AS A CAUSE OF POSTSTENOTIC DILATATION. , 1963, The American journal of cardiology.

[44]  A. Paterson,et al.  Simultaneous Occurrence of Intracranial Aneurysm and Arteriovenous Malformation , 1960, British medical journal.

[45]  R. Gibson,et al.  ANGIOGRAPHIC FINDING OF AN ANEURYSM AND ARTERIOVENOUS MALFORMATION IN THE POSTERIOR CRANIAL FOSSA IN A CASE OF SUBARACHNOID HAEMORRHAGE , 1960, Journal of neurology, neurosurgery, and psychiatry.

[46]  L. Lemmen,et al.  Cerebral aneurysms with other intracranial pathology. , 1960, Journal of neurosurgery.

[47]  J. S. Boyd-Wilson.  THE ASSOCIATION OF CEREBRAL ANGIOMAS WITH INTRACRANIAL ANEURYSMS , 1959, Journal of neurology, neurosurgery, and psychiatry.

[48]  P. Caram.  Simultaneous occurrence of intracranial aneurysm and angioma; case report. , 1959, Journal of neurosurgery.

[49]  R. Anderson,et al.  The association of arteriovenous angioma and saccular aneurysm of the arteries of the brain. , 1959, The Journal of pathology and bacteriology.

[50]  W. Mckissock,et al.  A clinical survey of intracranial angiomas with special reference to their mode of progression and surgical treatment: a report of 110 cases. , 1956, Brain : a journal of neurology.

[51]  F. Walsh,et al.  OCULAR SIGNS OF INTRACRANIAL SACCULAR ANEURYSMS: EXPERIMENTAL WORK ON COLLATERAL CIRCULATION THROUGH THE OPHTHALMIC ARTERY , 1942 .