Brain arteriovenous malformations (AVMs) are commonly associated with aneurysms. Aneurysms related to AVMs have a higher risk of bleeding and can be classified into four categories based on their location. Treatment of AVMs and aneurysms depends on factors like rupture history, location, and symptoms, and may involve surgery, endovascular procedures, or radiosurgery. Management goals include preventing rebleeding from the source of any previous hemorrhage.

1. Aneurysms Associated with Brain Arteriovenous Malformations
Ade Wijaya, MD
August 2017

2. Outline:
• Introduction
• Classification
• Pathogenesis
• Bleeding risk
• Management
• Conclusion

3. Introduction
• With improvement diagnostic technique, it’s known that brain AVM-related
aneurysms is more prevalent.
• Higher risk of cerebral hemorrhage
Rammos, S. K., Gardenghi, B., Bortolotti, C., Cloft, H. J., & Lanzino, G. (2016). Aneurysms associated with brain arteriovenous malformations.American
Journal of Neuroradiology, 37(11), 1966-1971.

4. Classification
Lv, X., Wu, Z., He, H., Ge, H., & Li, Y. (2016). Proposal of Classification of Aneurysms Coexisting with AVM and Possible Treatment
Strategies. Turkish neurosurgery, 26(2).

5. Pathogenesis
Flow-related
factors
Genetic
predisposition
Host-specific
characteristics
Redekop, G., TerBrugge, K., Montanera, W., & Willinsky, R. (1998). Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of
hemorrhage. Journal of neurosurgery,89(4), 539-546.

6. Pathogenesis
Hemodynamic
stress
IEL
remodeling
IEL loss
IEL
degeneration
Mandybur TI, Nazek M: Cerebral arteriovenous malformations: A detailed morphological and immunohistochemical study using
actin. Arch Pathol Lab Med 114:970-973, 1990

7. Pathogenesis
• AVMs supplied by posterial circulation  more commonly associated with
intracranial aneurysms
• Greater peak systolic pressure within the vertebrobasilar system, compared
with the anterior circulation
• AVM with aneurysms’ feeding arteries have smaller diameter, vessel
remodeling can not compensated increasing blood flow.
- Shakur, S. F., Amin-Hanjani, S., Mostafa, H., Charbel, F. T., & Alaraj, A. (2015). Hemodynamic characteristics of cerebral arteriovenous malformation feeder
vessels with and without aneurysms. Stroke, 46(7), 1997-1999.
- Morgan, M. K., Alsahli, K., Wiedmann, M., Assaad, N. N., & Heller, G. Z. (2015). Factors associated with proximal intracranial aneurysms to brain arteriovenous malformations: a
prospective cohort study. Neurosurgery, 78(6), 787-792.

8. Bleeding Risk
Higher risk of bleeding:
• Larger aneurysm
• Older patients
• Infratentorial
• Willis Circle aneurysm
Lower risk of bleeding:
• Venous ectasia
Hetts, S. W., Cooke, D. L., Nelson, J., Gupta, N., Fullerton, H., Amans, M. R., ... & Higashida, R. T. (2014). Influence of patient age on angioarchitecture of
brain arteriovenous malformations. American Journal of Neuroradiology, 35(7), 1376-1380.

9. Management
Treatment modality:
• Surgery
• Endovascular treatment
• Radiosurgey
van Beijnum, J., van der Worp, H. B., Buis, D. R., Salman, R. A. S., Kappelle, L. J., Rinkel, G. J., ... & Klijn, C. J. (2011). Treatment of brain arteriovenous
malformations: a systematic review and meta-analysis. Jama, 306(18).

10. Management
Treatment approaches:
• No consensus
• Case by case
• Based on anatomical location, rupture, and other factors
• Clinical experiences
Kim, E. J., Halim, A. X., Dowd, C. F., Lawton, M. T., Singh, V., Bennett, J., ... & UCSF BAVM Study Project. (2004). The relationship of coexisting extranidal
aneurysms to intracranial hemorrhage in patients harboring brain arteriovenous malformations. Neurosurgery, 54(6), 1349-1358.

11. Management
• If the source of hemorrhage is the aneurysm  treat the aneurysm as soon as
possible.
• If the AVM nidus is in proximity of the ruptured aneurysm  treat both
simultaneously in single operation
• Proximal flow-related aneurysm  surgery or endovascular
• Treatment of AVM can be done later by surgery, endovascular, radiosurgery, or even
conservative approach.
• Pseudoaneurysms  endovascular; most located in perforating artery difficult to
accessed by surgery
Crowley, R. W., Ducruet, A. F., McDougall, C. G., & Albuquerque, F. C. (2014). Endovascular advances for brain arteriovenous malformations. Neurosurgery,74(suppl_1), S74-
S82.

12. Management
• If the source of bleeding is the AVM, treatment can be delayed, since the risk of
rebleeding is low
• In unruptured cases, treating the AVM will regress the distal flow-related aneurysms
• AVM treated with radiosurgery will increase risk of aneursyms rupture. Therefore,
in these patients aneurysms need to be treated either by surgery or endovascular
treatment
• Arterial bifurcation aneurysms need to be treated before the AVM treatment due to
higher risk of bleeding during AVM treatment.
- Kano, H., Kondziolka, D., Flickinger, J. C., Yang, H. C., Park, K. J., Flannery, T. J., ... & Lunsford, L. D. (2012). Aneurysms increase the risk of rebleeding after stereotactic
radiosurgery for hemorrhagic arteriovenous malformations.Stroke, 43(10), 2586-2591.
- Mjoli N, Le Feuvre D, Taylor A: Bleeding source identification and treatment in brain arteriovenous malformations. Interv Neuroradiol 17:323-330, 2011
- Redekop G, TerBrugge K, Montanera W, Willinsky R: Arterial aneurysms associated with cerebral arteriovenous malformations: Classification, incidence, and risk of hemorrhage. J Neurosurg 89:539-
546, 1998

13. Management

14. Conclusion
• AVM-related aneurysms are quite common
• Higher risk of bleeding
• Classified into 4 categories:
- proximal flow-related aneurysms
- distal flow-related aneurysms
- intranidal aneurysms
- Unrelated aneurysms
• Management is case by case based on the clinical symptoms, anatomical location, and clinical
experience