Endovascular Treatment of Intracranial Ruptured Aneurysms Associated with Arteriovenous Malformations: A Clinical Analysis of 14 Hemorrhagic Cases

Abstract

<jats:p> This study investigated and summarized endovascular therapeutic strategies for intracranial ruptured aneurysms associated with arteriovenous malformations (AVMs). Between June 2005 and June 2009, we identified 16 aneurysms in 14 hemorrhagic cases of intracranial AVM using digital subtraction angiography (DSA). Of the 16 aneurysms, 14 were ruptured and two were unruptured. Aneurysms were classified as types I to IV, and were treated. Aneurysm treatment was followed by AVM treatment via various therapies, including embolization, gamma knife radiotherapy, or follow-up and observation to reduce the risk of aneurysm rupture or intracranial hemorrhage. Over a follow-up period ranging from six months to one year, none of the patients had aneurysm ruptures or intracranial hemorrhage. Most (13/14) patients had a Glasgow Outcome Scale (GOS) score of 5, and one patient had a score of 4. Sixteen aneurysms were treated successfully, as confirmed by DSA examination, and no AVMs re-grew. Clinical therapeutic strategies for intracranial ruptured aneurysms associated with AVMs should include aneurysm treatment first to reduce the risk of rupture and intracranial hemorrhage, eventually leading to a better prognosis. </jats:p>

Disappearance of a Ruptured Distal Flow–Related Aneurysm after Arteriovenous Malformation Nidal Embolization

“…None of our aneurysms regressed with direct AVM nidal treatment as the primary treatment (internal unpublished data). It is hypothesized that hemodynamic stress secondary to the high-flow nature of AVMs likely causes continual damage to the endothelia of blood vessels, leading to aneurysm formation, and over time these weakened blood vessels have a propensity to rupture (1,7,10,16,25). To our knowledge, this is the first reported case of resolution of ruptured AVM-associated aneurysm after treatment of nidus from unrelated, distant arterial feeders.…”

“…There remains controversy with regards to whether all AVM-associated aneurysms should be treated and, if so, the exact timing of aneurysm treatment relative to AVM treatment (5,15,23,25). Current trends would favor treatment of ruptured aneurysms given their higher likelihood of rerupture (5,15,22,25).…”

“…Endovascular treatment with coil embolization of larger feeding pedicle aneurysms or liquid embolic treatment of more distal aneurysms have been well reported in the literature with good efficacy and safety profile (6,11,15,25). Given the complex high-flow hemodynamics of AVMs and the relative anatomic relationships of the aneurysm to nidus, it is generally difficult to concurrently treat both pathologies in the same setting, even endovascularly (25). For unruptured aneurysms, there is a paucity of definitive guidelines for prophylactic aneurysm treatment (5,19,25).…”

“…Current trends would favor treatment of ruptured aneurysms given their higher likelihood of rerupture (5,15,22,25). Endovascular treatment with coil embolization of larger feeding pedicle aneurysms or liquid embolic treatment of more distal aneurysms have been well reported in the literature with good efficacy and safety profile (6,11,15,25). Given the complex high-flow hemodynamics of AVMs and the relative anatomic relationships of the aneurysm to nidus, it is generally difficult to concurrently treat both pathologies in the same setting, even endovascularly (25).…”

“…Hemodynamic changes, such as increased blood flow or changes in intravascular pressure, are associated with rupture of these AVM-associated aneurysms. Treatment strategies for these aneurysms are particularly challenging (25). Here, we report the case of an AVM-associated aneurysm causing intraventricular hemorrhage that disappeared after subsequent embolization of the nidus from pedicles not directly feeding the aneurysm.…”