THE MANAGEMENT OF PATIENTS WITH ARTERIOVENOUS-MALFORMATIONS AND ASSOCIATED INTRACRANIAL ANEURYSMS

OBJECTIVE: Few published studies have focused specifically on the uniq ue management issues encountered in treating patients with arterioveno us malformations (AVMs) and associated intracranial aneurysms. The pri mary objective of this study was to retrospectively review the clinica l and radiographic features of these patients. METHODS: Medical record s of all patients seen at Stanford University Hospital between 1988 an d 1996 with a diagnosis of AVMs were retrospectively reviewed. Aneurys ms were identified by conventional angiography and characterized by si ze, number, and location relative to the AVMs. AVMs were graded accord ing to the Spetzler-Martin scale. Odds ratios were calculated for the risk of intracranial hemorrhage. Variables included age, sex, number o f aneurysms, and AVM grade. RESULTS: Forty-five of 600 patients (7.5%) were identified as having coexisting intracranial aneurysms. All 45 p atients had high-flow malformations, and 58% had AVMs of Spetzler-Mart in Grade IV or higher. A majority of patients had multiple aneurysms. There was a statistically significant increase in AVM hemorrhage in fe male patients (odds ratio, 8.53 [1.87-38.98]; P < 0.005). There was no statistically significant correlation between the development of hemo rrhage and either age, AVM grade, or the number of aneurysms. Twenty-t hree patients (51%) presented with intracranial hemorrhage: bleeding o ccurred from the AVMs in 15 and from ruptured aneurysms in 5, and the source of the bleeding could not be determined in 3. Overall, nine pat ients (20%) bled from ruptured aneurysms: five at presentation, two du ring or within 3 weeks of AVM treatment, and two from new aneurysms. T wo of these nine patients died as a direct result of aneurysmal subara chnoid hemorrhage. Five patients (11%) developed new aneurysms. CONCLU SION: Aneurysms associated with AVMs are at risk for rupture before, d uring, and immediately after treatment of the AVMs. New aneurysms may arise in patients with high-flow AVMs. The risk of intracranial hemorr hage from either source is higher in female patients. To reduce the co mplications of intracranial hemorrhage in these patients, we recommend a management protocol designed to treat the aneurysms by surgical or endovascular means before administering definitive therapy for the AVM s. Meticulous intraoperative blood pressure control and fluid manageme nt during aneurysm surgery is critical to avoid hemorrhage from the AV Ms.