Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage

Gary Redekop M.D., M.Sc., F.R.C.S.(C) 1 , Karel TerBrugge M.D., F.R.C.P.(C) 1 , Walter Montanera M.D., F.R.C.P.(C) 1 , and Robert Willinsky M.D., F.R.C.P.(C) 1
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  • 1 Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada; and the Brain Vascular Malformation Study Group, The University of Toronto, Toronto, Canada
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Object. The goal of this study was to develop a classification system for aneurysms associated with arteriovenous malformations (AVMs) based on their anatomical and pathophysiological relationships and to determine the incidence and bleeding rates for these aneurysms as well as the effects of AVM treatment on their natural history.

Methods. Of 632 patients with AVMs, intranidal aneurysms were found in 35 (5.5%) and flow-related aneurysms in 71 (11.2%). Patients with intranidal aneurysms presented more frequently with hemorrhage (72% compared with 40%, p < 0.001) and had a 9.8% per year risk rate of bleeding during follow-up review. Twelve (17%) of the patients with flow-related aneurysms associated with an AVM presented with hemorrhage from an aneurysm, whereas 15 (21%) bled from their AVM. Seventeen patients underwent angiography after AVM treatment (mean 2.25 years). Of 23 proximal aneurysms, 18 (78.3%) were unchanged, four (17.4%) were smaller, and one (4.3%) had disappeared, whereas four (80%) of five distal aneurysms regressed completely and one was unchanged. Sixteen patients underwent angiography after partial AVM treatment (mean 3.8 years). In cases with less than a 50% reduction in the AVM, no aneurysms regressed, although two enlarged and bled. In cases with greater than a 50% reduction in the AVM, two of three distal aneurysms disappeared and five proximal aneurysms were unchanged.

Conclusions. Arterial aneurysms associated with cerebral AVMs may be classified as intranidal, flow-related, or unrelated to the AVM nidus. Intranidal aneurysms have a high correlation with hemorrhagic clinical presentation and a risk of bleeding during the follow-up period that considerably exceeds that which would be expected in their absence. Patients with flow-related aneurysms in association with an AVM may present with hemorrhage from either lesion. Aneurysms that arise on distal feeding arteries near the nidus have a high probability of regressing with substantial or curative AVM therapy.

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Contributor Notes

Address reprint requests to: Gary Redekop, M.D., F.R.C.S.(C), Division of Neurosurgery, The University of British Columbia, 323-C, 700 West 10th Avenue, Vancouver, British Columbia V52 4E5, Canada.
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