✓ The authors conducted a long-term follow-up study of 168 patients to define the natural history of clinically unruptured intracranial arteriovenous malformations (AVM's). Charts of patients seen at the Mayo Clinic between 1974 and 1985 were reviewed. Follow-up information was obtained on 166 patients until death, surgery, or other intervention, or for at least 4 years after diagnosis (mean follow-up time 8.2 years). All available cerebral arteriograms and computerized tomography scans of the head were reviewed. Intracranial hemorrhage occurred in 31 patients (18%), due to AVM rupture in 29 and secondary to AVM or aneurysm rupture in two. The mean risk of hemorrhage was 2.2% per year, and the observed annual rates of hemorrhage increased over time. The risk of death from rupture was 29%, and 23% of survivors had significant long-term morbidity. The size of the AVM and the presence of treated or untreated hypertension were of no value in predicting rupture.
Robert D. Brown Jr., David O. Wiebers, Glenn Forbes, W. Michael O'Fallon, David G. Piepgras, W. Richard Marsh and Robert J. Maciunas
Robert D. Brown Jr., David O. Wiebers and Glenn S. Forbes
✓ Among 91 patients with unruptured intracranial arteriovenous malformations (AVM's), 16 patients had 26 unruptured intracranial saccular aneurysms. An actuarial analysis showed the risk of intracranial hemorrhage among patients with coexisting aneurysm and AVM to be 7% per year at 5 years following diagnosis compared to 1.7% for patients with AVM alone. The difference in length of survival free of hemorrhage was significant (log-rank, p < 0.0007). Several angiographic and clinical parameters were investigated to better understand the relationship of these lesions. The aneurysms occurred in similar percentages in patients with small, medium, and large AVM's. Twenty-five aneurysms were on arteries feeding the malformation system, almost equally distributed proximally and distally. Eleven aneurysms were atypical in location, and all arose from primary or secondary branch feeders to the malformation; 24 were on enlarged feeding arteries. Eleven (16%) of the 67 patients with high-flow AVM's had associated aneurysms, compared with five (21%) of the 24 patients with low-flow AVM's. Four (16%) of 25 low-shunt malformations and 12 (18%) of 65 high-shunt malformations had associated aneurysms. All five aneurysms associated with low-shunt malformations were on a direct arterial feeder of the malformation. These data suggest that the intracranial AVM's predispose to aneurysm formation within AVM feeding systems and that the mechanism is not simply based upon the high blood flow or high arteriovenous shunt in these systems.
Robert D. Brown Jr., David O. Wiebers and Douglas A. Nichols
✓ This long-term follow-up study of 54 patients clarifies the angiographic predictors of intracranial hemorrhage (ICH) and clinical outcome in individuals with unoperated intracranial dural arteriovenous fistulae (AVF's). All of these patients were examined at the Mayo Clinic between 1976 and 1989, and all available cerebral arteriograms were reviewed by a neuroradiologist. Follow-up information was obtained for 52 patients (96%) until death or treatment intervention, or for at least 1 year after diagnosis, with a mean follow-up period of 6.6 years.
Throughout this 6.6-year follow-up period, ICH related to dural AVF occurred in five of the 52 patients, for a crude risk of hemorrhage of 1.6% per year. The risk of hemorrhage at the time of mean follow-up examination was 1.8% per year. Angiographic examination revealed several characteristics that were considered potential predictors of ICH during the follow-up period. Lesions of the petrosal sinus and straight sinus had a higher propensity to bleed, although the small numbers in the series precluded a definite conclusion. A person suffering from a dural AVF with a venous varix on a draining vein had an increased risk of hemorrhage, whereas no hemorrhage was seen in the 20 patients without a varix (p < 0.05). Lesions draining into leptomeningeal veins had an increased occurrence of hemorrhage, although this increased risk was not statistically significant. Patients' initial symptoms were compared to those at follow-up evaluation. Pulsatile tinnitus improved in more than half of the 52 patients, and resolved in 75% of those showing some improvement. Individuals without a sinus or venous outflow occlusion at initial cerebral angiography were more likely to improve or remain stable (89%), whereas patients with an occlusion showed infrequent improvement (11%; p < 0.05).
Robert D. Brown Jr., David O. Wiebers, James C. Torner and W. Michael O'Fallon
✓ The purpose of this study was to determine the symptoms at presentation and the incidence of intracranial hemorrhage (ICrH) caused by intracranial vascular malformations (IVMs) in a defined population. The authors used the Mayo Clinic medical records linkage system to detect all cases of IVM among residents of Olmsted County, Minnesota, during the period 1965 through 1992. Forty-eight IVMs were detected over the 27-year period. Twenty-nine of the 48 patients were symptomatic at presentation. The most common presenting symptom was ICrH, which was present in 20 patients, 69% of all symptomatic cases. Sixty-five percent of arteriovenous malformations (AVMs) presented with ICrH. The most common subtype of ICrH was intracerebral hemorrhage, which was found in nine of 20 patients; the second most common subtype was subarachnoid hemorrhage. The peak occurrence of hemorrhage was during the fifth decade of life. The age- and gender-adjusted occurrence of a first ICrH from an IVM among residents of Olmsted County, Minnesota was 0.82 per 100,000 person years (95% confidence interval 0.46–1.19). There was no increase in the detection of IVM-related ICrH throughout the study period. The 30-day mortality rate following ICrH was 17.6% for patients with an AVM and 25% for all patients with IVMs. This study provides unique data on symptoms at presentation and the incidence of ICrH and hemorrhage subtypes from IVMs on a population basis.
Douglas A. Nichols, Robert D. Brown Jr., Kent R. Thielen, Fredric B. Meyer, John L. D. Atkinson and David G. Piepgras
✓ The authors report their experience using electrolytically detachable coils for the treatment of ruptured posterior circulation aneurysms. Twenty-six patients with 28 posterior circulation aneurysms were treated. All patients were referred for endovascular treatment by experienced vascular neurosurgeons. Patients underwent follow-up angiography immediately after treatment, 1 to 6 weeks posttreatment, and 6 months posttreatment. Six-month follow-up angiograms obtained in 19 patients with 20 aneurysms demonstrated that 18 (90%) of the 20 aneurysms were 99 to 100% occluded, one aneurysm (5%) was approximately 90% occluded, and one aneurysm (5%) was approximately 75% occluded. The patient with the aneurysm that was approximately 75% occluded needed additional treatment, consisting of parent artery balloon occlusion, and was considered a treatment failure (3.8% of patients). There was one treatment-associated mortality (3.8%) but no treatment-associated serious neurological or nonneurological morbidity in the patient group. There was no recurrent aneurysm rupture during treatment or during the mean 27-month follow-up period.
Endovascular treatment of ruptured posterior circulation aneurysms with electrolytically detachable coils can be accomplished with low morbidity and mortality rates. The primary goal of treatment—preventing recurrent aneurysm—can be achieved over the short term.
Endovascular coil occlusion will play an important role in the treatment of ruptured posterior circulation aneurysms, particularly if long-term efficacy in preventing recurrent aneurysm hemorrhage can be documented.
David O. Wiebers, David G. Piepgras, Robert D. Brown Jr., Irene Meissner, James Torner, Neal F. Kassell, Jack P. Whisnant, John Huston III and Douglas A. Nichols
Thanh G. Phan, John Huston III, Robert D. Brown Jr., David O. Wiebers and David G. Piepgras
Object. The goal of this study was to determine the frequency of enlargement of unruptured intracranial aneurysms by using serial magnetic resonance (MR) angiography and to investigate whether aneurysm characteristics and demographic factors predict changes in aneurysm size.
Methods. A retrospective review of MR angiograms obtained in 57 patients with 62 unruptured, untreated saccular aneurysms was performed. Fifty-five of the 57 patients had no history of subarachnoid hemorrhage. The means of three measurements of the maximum diameters of these lesions on MR source images defined the aneurysm size. The median follow-up period was 47 months (mean 50 months, range 17–90 months).
No aneurysm ruptured during the follow-up period. Four patients (7%) harbored aneurysms that had increased in size. No aneurysms smaller than 9 mm in diameter grew larger, whereas four (44%) of the nine aneurysms with initial diameters of 9 mm or larger increased in size. Factors that predicted aneurysm growth included the size of the lesion (p < 0.001) and the presence of multiple lobes (p = 0.021). The location of the aneurysm did not predict an increased risk of enlargement.
Conclusions. Patients with medium-sized or large aneurysms and patients harboring aneurysms with multiple lobes may be at increased risk for aneurysm growth and should be followed up with MR imaging if the aneurysm is left untreated.
Kelly D. Flemming, David O. Wiebers, Robert D. Brown Jr., Michael J. Link, Hirofumi Nakatomi, John Huston III, Robyn McClelland and Teresa J. H. Christianson
Object. Nonsaccular intracranial aneurysms (NIAs) are characterized by dilation, elongation, and tortuosity of intracranial arteries. Dilemmas in management exist due to the limited regarding the natural history of this disease entity. The objective of this study was to determine the prospective risk of subarachnoid hemorrhage (SAH) in patients with vertebrobasilar NIAs.
Methods. All patients with vertebrobasilar fusiform or dolichoectatic aneurysms that had been radiographically demonstrated between 1989 and 2001 were identified. These patients' medical records were retrospectively reviewed. A prospective follow-up survey was sent and death certificates were requested. Based on results of neuroimaging studies, the maximal diameter of the involved artery, presence of SAH, and measurements of arterial tortuosity were recorded. Nonsaccular intracranial aneurysms were classified according to their radiographic appearance: fusiform, dolichoectatic, and transitional. Dissecting aneurysms were excluded. The aneurysm rupture rate was calculated based on person-years of follow up. Predictive factors for rupture were evaluated using univariate analysis (p < 0.05). One hundred fifty-nine patients, 74% of whom were men, were identified. The mean age at diagnosis was 64 years (range 20–87 years). Five patients (3%) initially presented with hemorrhage; four of these patients died during follow up. The mean duration of follow up was 4.4 years (692 person-years). Nine patients (6%) experienced hemorrhage after presentation; six hemorrhages were definitely related to the NIA. The prospective annual rupture rate was 0.9% (six patients/692 person-years) overall and 2.3% in those with transitional or fusiform aneurysm subtypes. Evidence of aneurysm enlargement or transitional type of NIA was a significant predictor of lesion rupture. Six patients died within 1 week of experiencing lesion rupture.
Conclusions. Risk of hemorrhage in patients harboring vertebrobasilar NIAs is more common in those with evidence of aneurysm enlargement or a transitional type of aneurysm and carries a significant risk of death.