J Heart Stroke | Volume 3, Issue 1 | Research Article | Open Access
Shchehlov DV1*, Bortnik IM1, Svyrydyuk OE1 and Mamonova MY2
1Department of Endovascular Neuroradiology, Ukraine
2Department of Cardiologie, National Medical University, Ukraine
*Correspondance to: Shchehlov DV
Fulltext PDFBackground: Brain arteriovenous malformations (AVM) are frequently associated with the presence of intracranial arterial aneurysms (AA), which increase the hemorrhage rate and therefore are associated with more unfavorable outcomes. Here we report our clinical experience of endovascular treatment AVMs associated with AA.
Materials and Methods: To evaluate the incidence of AVM associated with AA, the authors reviewed 421 cases of patients with AVMs managed between 2004 and 2016 that were treated at our clinic. In 91 (21.6%) of these 421 patients, we observed 67 (59,8 %) intranidalAA, 25 (22,3 %) flowrelated AA of vessels supplying the AVMs, 17 (15,2 %) AA of the circle of Willis origin of an artery supplying to the AVM and 3 (2, 7 %) AA of remote artery that was not involved in the AVM supply. In all cases endovascular treatment with coils, n-butyl cyanoacrylate (NBCA), Onyx and Embolin was performed. We investigate the radiological findings, treatment strategy, clinical courses and outcomes.
Results: 112AA in 91 patients with AVMs were studied. Hemorrhage was the most frequent presenting symptom in63 patients (69,2 %), seizures in 24 (26,3 %) patients, 4 (4,5 %) patients had other symptoms, and were accidental finding (routine computer topography (CT), magnetic resonance imaging (MRI) reveled AVMs, digital subtraction angiography (DSA) - associated AA). The source of hemorrhage in those who had bled was deduced from angiographic findings correlated with CT, MRI and DSA. We found that 43 (68,2 %) hemorrhagic cases were caused by AVM rupture with intranidal AA, 12 (19,1 %) cases by rupture of AA of vessels supplying the AVMs, 7 (11,2 %) - AA of the circle of Willis origin of an artery supplying to the AVM, 1 (1,5 %) - remote AA that was not involved in the AVM supply. AA that were treated directly at the time of surgical or endovascular AVM treatment. Twenty oneAA were coiled and other 82 flow-related and intranidal AA were embolized with Embolin, NBCA and Onyx18. There were eight patients with AVM, with nine associated AA who did not receive any treatment for their AA, two of them with three AA died because of terminal coma after hemorrhage. Three patients had fusiform flowrelated AA, that were left for observation, 1 patient had proximal flow-related arterial Anterior Communicating Artery (ACoA) microaneurysm with a complicated afferent vessels anatomy that was hard to occlude but it regress after subtotal AVM treatment, and 2 patients reject any surgery. All 91 patients had clinical follow-up from 1 month to 12 years. None of the coiled AA reanalyzed. One (0, 89 %) hemodynamically related AA regressed during follow-up, and none of the residual AA rupture during the follow-up period. Five patients showed de-novo AA formation after subtotal AVM obliteration, all of them in cases of flow-related AA.
Conclusion: The type of endovascular treatment depend on the site of AA and its relationship to the nidus of the AVM. The main policy is to treat the symptomatic lesion first. Discovery of AA during AVM evaluation should turn it in the therapeutic focus. The method of choice is the simultaneous AA and AVM occlusion. Occlusion of associated AA is critical.
Arteriovenous malformations; Intracranial arterial aneurysms associated with arteriovenous malformations; Endovascular treatment
Shchehlov DV, Bortnik IM, Svyrydyuk OE, Mamonova MY. Endovascular Treatment of Intracranial Aneurysms Associated with Arteriovenous Malformations. J Heart Stroke. 2018; 3(1): 1045.