Article
Multimodal treatment of arteriovenous malformations with associated aneurysms: A single center experience
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Authors
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J. Platz
- Klinik und Poliklinik für Neurochirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
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R. Wolff
- Gamma Knife Frankfurt, Frankfurt am Main
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J. Berkefeld
- Institut für Neuroradiologie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
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V. Seifert
- Klinik und Poliklinik für Neurochirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
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H. Vatter
- Klinik und Poliklinik für Neurochirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
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E. Güresir
- Klinik und Poliklinik für Neurochirurgie, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main
| Published: | June 4, 2012 |
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Outline
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Objective: Treatment and fate of AVM-related aneurysms is not evaluated extensively.
Methods: We retrospectively identified 38 patients with AVMs and associated aneurysms on at least one parent artery. We report the clinical and morphological features and the individualized, tailored treatment using a multimodal approach.
Results: Mean age at diagnosis was 48.9±15.9 years. Maximum diameter of the AVM was <3 cm in 65.8%, 3–6 cm in 31.6% and >6 cm in 2.6%. Deep venous drainage was found in 63.2%. AVMs were located supratentorial (52.6%), in the cerebellum (42.1%), and within the mesencephalon (5.3%). Hemorrhage was the first symptom of the AVM in 60.5% (18 patients presented with subarachnoid hemorrhage, 5 with intracerebral hematomas). The associated aneurysm was regarded as source of the hemorrhage in 21 (91.3%) cases. In case of hemorrhagic presentation, treatment of the ruptured aneurysm was endovascular in 14 patients (60.9%) and surgically in 5 patients (21.7%) including resection of the AVM in two cases. In 4 patients (17.4%), no treatment was possible. 4 patients died due to the initial hemorrhage. The AVM was treated in 8 patients in the post-acute phase: Treatment was surgical in 3 patients, endovascular in 2 and by Gamma-knife in 3 patients. 6 patients refused the recommended treatment of the AVM. In the other patients, there was no safe therapy due to the complex nature of the malformation. 7 patients suffered from repeated hemorrhage of their AVM (n=4 had refused treatment and n=2 of those without treatment option). Of the 15 patients without initial hemorrhage, the aneurysm was treated endovascular in 4 cases, surgically in 4 (including AVM resection), and not treated directly in 7 patients. Of those, the AVM was treated surgically in 1, by Gamma knife in 2 and in a combined surgical and endovascular procedure in 1 patient. Delayed intracerebral hemorrhage occurred in 4 patients between 4 and 59 months after diagnosis of a previously unruptured AVM. All patients had denied treatment before.
Conclusions: AVMs with associated aneurysms do have a rather high percentage of hemorrhage at presentation. In our series, the aneurysm was the bleeding source in most cases. Treatment in an individually tailored, staged interdisciplinary approach seems safe and effective.
