Surgical management of intracranial arteriovenous malformation associated with aneurysms

The association of intracranial arteriovenous malformation (AVM) with aneurysm(s) is hazardous, and various forms of treatment have been suggested. Most authors agree that surgery for these combined lesions should be directed toward the symptomatic lesion first. This may be difficult, however, especially when the source of the hemorrhage is unclear.

Between 1985 and 1996, 12 patients with combined AVM and aneurysm(s) were treated at this institution. Clinical presentations included headache and hemorrhage in all patients, limb weakness in three patients, and seizure in one patient. Hemorrhage types included subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH). To avoid the intraoperative rupture of aneurysms during resection of the AVM, these were routinely clipped first, followed by total extirpation of the AVM.

SAH, ICH and/or IVH simultaneously presented in seven patients (58.3%). According to the surgical findings, bleeding resulted from the aneurysm in 10 patients and AVM in two patients. There was a high incidence of combined lesions in the posterior circulation (67%) in our series. Among the patients with combined lesions in the posterior circulation, half had multiple aneurysms. A total of 21 aneurysms were found in the 12 patients, with five patients harboring multiple aneurysms. Among the 12 patients, 10 had good results. Eight patients received one-stage operations and two received two-stage operations. Two patients died, one of massive rebleeding from multiple giant aneurysms with SAH, IVH and ICH after ventricular drainage, and the other died of massive bleeding during resection of a large AVM.

It is difficult to predict bleeding sources preoperatively by radiologic images. Our experience has led to the belief that the safest approach is to treat the aneurysm before microsurgical resection of the AVM. Most of our patients were surgically treated in one approach and showed good results.