Multiple intracranial aneurysms and vascular malformations in an infant. Case report

Associated aneurysms in pediatric arteriovenous malformations and the implications for treatment

BACKGROUND

Arteriovenous malformations (AVM) with associated aneurysms (AA) increase the risk of hemorrhage in adults. Associated aneurysms are thought to develop over time, and the incidence in children, therefore, has been thought to be minimal, although this has not yet been studied.

OBJECTIVE

To define the incidence and morbidity of AA in children and to assess the results of our treatment strategy.

METHODS

Patients younger than 18 years of age with pial AVM seen from 2000 to 2009 were reviewed. Demographics, presentation, hemorrhage, AAs, treatment method, and outcome were analyzed.

RESULTS

Of 144 patients with AVM, 30 were younger than 18 years of age. AA was identified in 5 of 30 children (16.7%) and 33 of 114 adults (28.9%; P = .25). Mean age at presentation in children was 11.67 years (range, 6 months to 17 years), and mean follow-up was 28.8 months (range, 1-75 months). Hemorrhage at presentation was seen in 80% of patients with AA and 72% with AVM alone. Emergent therapy was required in 60% of patients with AA and 40% with AVM alone (P = .63). Time to treatment was 4.3 days with AA and 27.3 days without (P = .42). There was no difference in outcome between patients with AA and those with AVM alone.

CONCLUSION

The incidence of pediatric AA was higher in our series than projected in the current literature. Time to treatment was shorter in children with AA compared with those with AVM alone, although there was no difference in clinical outcome. Although hemorrhage rates were similar, emergent therapy was required more often in patients with AA. Our findings support the need for early diagnosis and treatment of associated aneurysms in children.

Secondary spontaneous thrombosis of a giant aneurysm located distally on a feeding artery after embolization of an associated arteriovenous malformation

SUMMARY

Giant aneurysm located in the distal part of the feeding artery associated with a cerebral arteriovenous malformation is rare and the treatment is clinically challenging. We report the spontaneous and complete thrombosis of a flow-related giant aneurysm immediate up-stream to a cerebral arteriovenous malformation by embolization of that malformation alone in a patient presenting with complex partial seizure and no history of intracranial haemorrhage. We obviated the need to directly intervene on the giant aneurysm, thus reducing unnecessary procedure related risks to the patient. Follow up one year later confirms the thrombosis and show shrinkage of the mass. The patient is asymptomatic.

The management of patients with arteriovenous malformations and associated intracranial aneurysms

OBJECTIVE

Few published studies have focused specifically on the unique management issues encountered in treating patients with arteriovenous malformations (AVMs) and associated intracranial aneurysms. The primary objective of this study was to retrospectively review the clinical and radiographic features of these patients.

METHODS

Medical records of all patients seen at Stanford University Hospital between 1988 and 1996 with a diagnosis of AVMs were retrospectively reviewed. Aneurysms were identified by conventional angiography and characterized by size, number, and location relative to the AVMs. AVMs were graded according to the Spetzler-Martin scale. Odds ratios were calculated for the risk of intracranial hemorrhage. Variables included age, sex, number of aneurysms, and AVM grade.

RESULTS

Forty-five of 600 patients (7.5%) were identified as having coexisting intracranial aneurysms. All 45 patients had high-flow malformations, and 58% had AVMs of Spetzler-Martin Grade IV or higher. A majority of patients had multiple aneurysms. There was a statistically significant increase in AVM hemorrhage in female patients (odds ratio, 8.53 [1.87-38.98]; P < 0.005). There was no statistically significant correlation between the development of hemorrhage and either age, AVM grade, or the number of aneurysms. Twenty-three patients (51%) presented with intracranial hemorrhage: bleeding occurred 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 patients (20%) bled from ruptured aneurysms: five at presentation, two during or within 3 weeks of AVM treatment, and two from new aneurysms. Two of these nine patients died as a direct result of aneurysmal subarachnoid hemorrhage. Five patients (11%) developed new aneurysms.

CONCLUSION

Aneurysms associated with AVMs are at risk for rupture before, during, and immediately after treatment of the AVMs. New aneurysms may arise in patients with high-flow AVMs. The risk of intracranial hemorrhage from either source is higher in female patients. To reduce the complications 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 AVMs. Meticulous intraoperative blood pressure control and fluid management during aneurysm surgery is critical to avoid hemorrhage from the AVMs.

[Aneurysm of the distal portion of the posterior and inferior cerebellar artery in a child]

The case of a 7-year-old boy presenting with recurrent episodes of subarachnoid hemorrhage due to a distal posterior inferior cerebellar artery aneurysm (PICA), successfully operated, is reported. The low incidence of intracranial aneurysms in the first decade of life and the rare occurrence of distal PICA aneurysms are unusual features of this case. The theories regarding the origin of intracranial berry aneurysms are discussed.

Intracranial arterial aneurysms in children. Clinical, neuroradiological and histological findings

Of our five cases of intracranial arterial aneurysms in children, there were two typical saccular aneurysms and three with fusiform or large peripheral vascular anomalies. Angiographic and histological examinations pointed to an additional arteriovenous malformation in the area of the aneurysm in two cases, combined in a third case with a cutaneous hemangioma of the brow. Other characteristics were typical of aneurysms in children such as low frequency, male preponderance, and location at the internal carotid artery bifurcation. Large peripheral aneurysms are not unusual in childhood. However, neuroradiological and neuropathological criteria reveal that such 'aneurysms' are often part of a complex arteriovenous malformation as has been presumed by some authors.

Cerebral arteriovenous malformations with associated arterial aneurysms: hemodynamic and therapeutic considerations

The common vascular anomalies of cerebral aneurysm and arteriovenous malformation may exist independently, or together as part of a closely related hemodynamic pairing. Resection or embolization of an AVM may be followed by a decrease in local blood flow, and lead to regression of a suitably situated proximal aneurysm. However, aneurysms located outside the angioarchitecture of the AVM, which remain flow-unrelated to the malformation, will likely not regress, and may in fact enlarge. Two cases are presented which demonstrate these vascular relationships, in order to better understand the regional hemodynamics of these anomalies prior to surgical or endovascular treatment planning.

Cerebral arteriovenous malformations (C. AVM) and associated arterial aneurysms (AA). Analysis of 101 C. AVM cases, with 37 AA in 23 patients

We report a series of 101 patients with cerebral arteriovenous malformations (CAVM), in which 23 cases presented with one or several arterial aneurysm(s) (AA). Each AA could be classified into distal intra-lesional, proximal or remote. Patients with CAVM + AA tend to be older and more frequently present with epilepsy, haemorrhage events and neurological deficits. Of these 23 patients, 16 had their AVM treated partially or totally by embolization. In our series, the endovascular treatment of the arteriovenous shunt with a proximal AA on the same vessel has resulted in at least a regression, and sometimes a disappearance of the arterial ectasia. Although partial treatment of the AVM does no erase the risk of haemorrhage from the malformation itself, it may diminish the chance of developing a flow-related AA or any other expression of the high-flow angiopathy.

Multiple intracerebral arteriovenous malformations. A case report and literature review

The presence of multiple intracerebral arteriovenous malformations (AVMs) in a single patient has only been very rarely reported. We present a patient with three separate angiographically demonstrable intracerebral AVMs, all of which were radiologically demonstrated and surgically removed without residual neurological deficit. A literature survey was conducted and all the previously described cases of multiple intracerebral AVMs are discussed, along with the potential diagnostic and therapeutic implications.

Features of intracranial aneurysms in infants and report of a case

An 11-month-old girl presented with seizures, papilledema and a left hemiparesis. Radiographic examination revealed a saccular right middle cerebral-artery aneurysm. Clipping was performed 16 days after admission. At follow-up a year later there was no residual neurological deficit. Aneurysms occurring in infants are relatively large and more peripheral in location compared with adults, and frequently are accompanied by seizures. Infants' aneurysms also tend to occupy the anterior circulation distribution, and their peripheral location may make them more amenable to surgical intervention.

Intracranial aneurysms and subarachnoid hemorrhage in children and adolescents

Thirty-eight cases of symptomatic cerebral aneurysms or spontaneous subarachnoid hemorrhage in children and adolescents were observed from 1965 to 1984; 33 cases were treated from 1970 to date. This group represents 2.6% of the total number of patients with subarachnoid hemorrhage treated at our institute in the same period. The cause of subarachnoid hemorrhage was unknown in 7 cases; an intracranial aneurysm had ruptured in 29 cases, and was unruptured but symptomatic in 2 remaining cases. Three aneurysms were mycotic. The most frequent aneurysmal locations were the internal carotid bifurcation and the anterior communicating artery; peripheral branches of the middle cerebral artery were also a relatively common location. Four patients were 3 years of age or younger: each presented peculiar clinical features, and 3 of the 4 had middle cerebral artery aneurysms. The remaining 34 patients were all above 9 years of age. Two groups were identified: (a) in 14 patients between 10 and 15 years of age, the aneurysm was most commonly at the internal carotid bifurcation (37%), and an intracerebral hematoma was observed in 50% of these cases; (b) in 20 patients between 16 and 20 years of age, the most common aneurysmal location was the anterior communicating artery (35%), and intracerebral hematomas were rare (10% of cases). Among patients with aneurysms, 19 underwent surgical exclusion by clip, with 10% morbidity and 5% mortality; 5 patients in moribund conditions were not operated on; 5 patients were conservatively treated; in 2 patients the aneurysm had disappeared at a second angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteriovenous malformations of the brain: a teratologic challenge

Congenital arteriovenous malformations of the brain are lesions which are well-known to neurologists and neurosurgeons but are puzzling to teratologists because they occur sporadically and are unassociated with congenital malformations outside the central nervous system. They are recommended to teratologists as a field of etiologic and pathogenetic research.

[Spontaneous thrombosis of a giant aneurysm after excision of an associated vascular malformation. Report of a case]

A case of a patient with a giant aneurysm of the left middle cerebral artery and a huge arteriovenous malformation hemodynamically related is reported. Complete thrombosis of the aneurysm was observed after extirpation of the arteriovenous malformation as shown by angiography one week, six months and a year post-operatively. Reduction of the regional cerebral blood flow after extirpation of the arteriovenous malformation and the natural tendency of these giant aneurysms to partially thrombose were to be the explanation for our results.

Association of intracranial aneurysm and arteriovenous malformation

In a series of 252 patients (47 with arteriovenous malformation, 205 with aneurysms), two patients had a coexisting intracranial aneurysm and an arteriovenous malformation. In one patient, the aneurysm was proximal to the main feeding arteries of the arteriovenous malformation. In the other patient, there was no anatomical relationship between the two lesions. These findings illustrate different views on the pathogenesis of the rare association of the two conditions.

The association of intracranial aneurysms and arteriovenous malformation of the brain. Case report

A case of intracranial multiple aneurysms associated with an arteriovenous malformation (AVM) is described. Three aneurysms were found arising from an enlarged anterior cerebral artery feeding an AVM. In spite of the fact that two of these aneurysms received no surgical treatment, they disappeared almost completely several months after excision of the AVM. Seventy-three previously reported cases of cerebral aneurysms associated with AVM's are reviewed, and the effect of hemodynamic stresses on the development of these aneurysms is summarized.

Saccular aneurysm of infancy and early childhood: report of a case

A case of intracranial saccular aneurysm with intracerebral haematoma occurring in early childhood and presenting with sudden loss of consciousness and right hemiparesis is reported. The aneurysm was located in the opercular portion of the left middle cerebral artery. Surgery, besides removing the intracerebral haematoma, involved clipping and complete removal of the aneurysmal sac. The child made an uneventful recovery, and he is completely safe after 40 months. Microscopic examination of the lesion shows disruption of the normal sequence of the original layers, with widespread inflammatory cells.

Cerebral aneurysm in an infant with fibromuscular hyperplasia of the renal arteries. Case report

The authors report a case of subarachnoid hemorrhage in an 11-month-old infant with tragic outcome. Radiological investigation showed an anterior communicating aneurysm, and postmortem examination confirmed the aneurysm to be a so-called "berry" aneurysm. There were also typical signs of fibromuscular hyperplasia of the renal arteries. The microscopic findings are discussed. In view of the rarity of both aneurysms and fibromuscular hyperplasia in such a small child, a possible association of these entities suggested by several earlier investigators is reviewed.

Giant thrombosed aneurysm associated with an arteriovenous malformation. Case report

The authors describe a case of giant anterior cerebral artery aneurysm associated with an anatomically related arteriovenous malformation (AVM). The aneurysm was almost completely thrombosed and was resected along with the AVM.

[Bilateral cerebral mycotic aneurysm in a child. Report of a case and review of the literature]

The case of a 6 year-old boy, who was hospitalized with the diagnosis of purlent meningits is reported. The CSF examination disclosed pleocytosis and the antibioticotherapy was instituded. The bilateral carotid angiography demonstrated an arterial aneurysm of the frontal ascendent artery with hematoma in the left side and another in the posterior temporal artery, in the right side. The patient was operated on because of the hematoma, in the left side. The condition of the patient in the post-operatory period deteriorated and the death ocurred. The post-mortem examination disclosed a sub-arachnoidal hemorrhage, fronto-temporal hematoma in the left side and a para-capsular hematoma in the right side. The histological examination of the central part of the right side. The histological examination of the central part of the hematoma revealed a dilated arterial walls with a supurative inflammatory process.