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Pseudoaneurysms Within Ruptured Intracranial Arteriovenous Malformations: Diagnosis and Early Endovascular Management

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Pseudoaneurysms Within Ruptured Intracranial Arteriovenous Malformations: Diagnosis and Early Endovascular Management Pseudoaneurysms within Ruptured Intracranial Arteriovenous Malformations: Diagnosis and Early Endovascular Management Ricardo Garcia-Monaco, 1 Georges Rodesch, 1 Hortensia Alva rez, 1 Yuo lizuk a, 1 Francis Hui, 1 and Pierre Lasjaunias 1 PURPOSE: To draw attention to pseudoaneurysm s within ruptured arteriovenous malformations and to consider their diagnostic and therapeutic features, including pitfalls and precautions needed for safe emboli zation. METHODS: Radiologic and clinical charts of 189 patients who bled from intracranial arteriovenous m alformations were retrospectively reviewed. RESULTS: Fifteen of the 189 (8%) were found to have pseudoaneurysm s. Nine of the pseudoaneurysms were arterial, six were venous. In the ea rly period following hemorrhage, nine patients were trea ted conservatively. The other six were trea ted with surgery (one case) or embolization (five cases) because urgent intervention was required. The clinical outcome for both conservative and interventional groups was generally favorable , but one patient in the conservati ve group died of a rebleed. In the patients who underwent embolization, the fragile nature of the pseudoaneurysm made it necessary to fi rst embolize the artery feeding it. Embolization with particles was considered haza rdous. Instead, free­ flow (nonwedged) N-butyl-cyanoacrylate embolization proved sa fe and effective in treating both the pseudoaneurysm s and arteriovenous malformations in these cases. CONCLUSIONS: This study highlights the importance of recognizing pseudoaneurysm s in such patients and the importance of using free-flow liquid adhesive m aterial on the artery feeding the pse udoaneurysm if embolization is required. Index terms: Aneurysm s, cerebral; Arteriovenous m alformations, cerebral; Cerebra l hemorrhage; Aneurysm emboli za tion; lnterventional neuroradiology, com plications of AJNR 14:315-321 , Mar/ Apr 1993 Approximately 42% to 50% of patients with the A Y M because it suggests the exact site of cerebral arteriovenous malformations (A Y Ms) rupture and bleeding. In addition, because pseu­ present with intracranial bleeding (1, 2). Previous doaneurysms lack true walls, embolization may reports have commented on the angioarchitec­ be hazardous and lead to intraprocedural rupture ture of A Y Ms and the relation to their hemor­ and cerebral hemorrhage (9). In this paper, we rhagic episodes (3-6). Detailed analysis has also will draw attention to pseudoaneurysm s within focused on identification of areas of fragility ruptured A Y Ms and consider their diagnostic and within the A Y M and the host in an effort to predict therapeutic features, including pitfalls and pre­ those patients who are at risk of bleeding (7 , 8). cautions needed for safe embolization. Angiography, when performed in the acute phase of a hemorrhagic episode,· may show a pseudo­ Material and Methods aneurysm within the ruptured A Y M . Despite little attention in the literature, a pseudoaneurysm The rad iologic and clinical charts of 189 patients who when demonstrated is a remarkable feature of bled from in tracranial A V Ms were retrospectively reviewed. A ngiography showed a pseudoaneurysm within the A V M in 15 patients (8% ). Each patient's age, gender, type of Received January 2, 1992; revision requested April 9; revision received hemorrhage, type of vascular malformation, location of June 4 and accepted July 21. A V M and pseudoaneurysm, and ea rly and subsequent 1 Neuroradiologie Vasculaire Diagnostique et Therapeutique, Hopital Bicetre, Universite Pa ris Sud, 78 rue du General Leclerc, 94275 Krem lin treatment are summarized in Table 1. Embolization within Bicetre, France. Address reprint requests to Pierre Lasjaunias. 72 hours of cerebral hemorrhage was performed in five of A JNR 14:315-321 , Mar/ Apr 1993 0 195-6108/93/1402- 0315 the 15 patients. Table 2 summarizes the symptoms asso­ © American Society of Neuroradiology ciated with the hemorrhage, territory of embolization, im- 315 316 GARCIA-MONACO AJNR: 14, March/ April 1993 TABLE 1: Series of 15 patients with angiographically demonstrated pseudoaneurysms within a ruptured AVM Initial Subsequent Vasc ular Pseudo- Treatment Case Age Sex Hemorrhage Location Treatment Malformation aneurysm (within 72 of AVM hours) 1 6 mo M ICH AVF Paracentral Arterial Emboliza tion Further embolization 2 43 yr F IVH AVM Para splenial Venous Embolization Further embolization + radiotherapy 3 30 yr F IVH AVM Lateral ven- Venous Embolization tricle 4 23 yr M ICH AVM Temporal Arterial Embolization Radiotherapy 5 28 yr M SAH AVM Paracentral Venous Embolization Further embolization 6 4 yr M IVH AVM Thalamus Arterial Medical Therapeutic absten- tion 7 17 yr M ICH-IVH AVM Caudate nu- Arterial Medical Embolization + su r- deus gery 8 30 yr F IVH AVM Basal ganglia Venous Medical Early rebleed ing (died) 9 43 yr F ICH-IVH AVM Precentral Arterial Medical Embolization gyrus 10 18 yr F ICH AVM Basal ganglia Venous Medical Embolization 11 29 yr F ICH AVM Precuneus Venous Medical Embolization + sur- gery 12 6 mo F ICH Multiple AVMs Temporal Venous Medical Therapeutic absten- occipital tion 13 16 yr M IVH-ICH AVM T halamus Arterial Medical Radiotherapy 14 16 yr F ICH AVM Ca llosal Arterial Surgery 15 34 yr F IVH AVM In sular Arterial Medical Embolization Note. M =male; F= female; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; SAH = subarachnoid hemorrhage; AVF = arteri ovenous fistula; AVM = arteriovenous malformation. TABLE 2: Endovascular management of our series of five patients with pseudoaneurysms within AVMs Vessel A natomic Result Comple- Targeted Compli- Short-Term Long-Term Case Symptoms mentary Follow-Up for Em- Pseudo- cations Outcome Outcome AVM Treatment bolization• aneurysm Hemiparesis Rolandic Suboc- Unchanged Transient Recovery Further Asympto- 11 months Seizures artery elusion worsening (asympto- embo- matic of hemipa- matic) lization resis 2 Headaches Posteri or cal- Occlusion Red uction of Recovery Further em- Quadran- 8 months Confusion losal artery nidus (asympto- bolizationb opsia matic) + radio- therapy 3 Somnolence Posterior Occlusion Cure Recovery Asympto- 7 months Venous thrombo- choroidal (asympto- matic sis of upper artery matic) limb (requiring heparinization) 4 Somnolence Posterior Occlusion Red uction of Clinical im- Radiother- Quadran- 8 months Hemiparesis temporal nidus provement apy opsia Hemianopsia artery Residual quad- ranopsia 5 Hemiparesis Internal pari- Occlusion Reduction of Recovery Further em- Asympto- 10 months Hemianesthesia etal artery nidus (asympto- bolization matic matic) • Arterial feeder of the compartment of the A V M harboring the pseudoaneurysm. b After a second session of embolization, the patient developed a quadranopsia. AJNR: 14, March/ April 1993 RUPTURED A V Ms 3 17 ~ Fig. 1. Case I . A , Sagittal T1 -weighted MR . B, Initial internal ca rotid an­ giogram (l ateral view) shows a complex arteriovenous fi stula in the rolandic sulcus. C, Sagittal T1 -weighted MR done after the onset of sudden hemipares is 1 month later shows a hem atoma (asterisk ) surround­ ing a pseudoaneurysm (arrow) at the margin of the m alformation. 0 , Subsequent carotid angio­ gram (lateral view) clea rl y shows the pseudoa neurysm (arrow) as a new fea ture of the vascular malformation. A B c D mediate anatomic result (of both pseudoaneurysm and zation of the arterial pedicle at the selected point for A V M), complications, short-term outcome, complementary embolization, occlusion of the nidus and the false aneurysm treatment, long-term outcome, and follow-up of this latter or its arterial feeder were done with N-butyl-cyanoacrylate group. Urgent embolization was done in these patients (NBCA) (Bruneau, Boulogne, Fra nce) m ixed with Tanta lum because of progressive clinical deterioration (cases 1 and powder (Byodine, El Cajon, CA) and Lipiodol (G uerbet, 4), pressing need for systemic heparinization to treat an Villepinte, France). upper limb venous thrombosis (case 3), and fear of early hemorrhagic recurrence from the demonstrated bleeding Results point (cases 2 and 5). Embolization was done by the transarterial route in al l We found nine arterial and six venous pseu­ patients after a percutaneous femoral puncture. The pro­ doaneurysms within A V Ms in our series. There cedures were done under neuroleptic analgesia or general was no sex predominance. Pseudoaneurysms anaesthesia, depending on the age and clinical status of were found in both cortical (eight cases) and deep the patients. Selective catheterization of the arterial pedicle (seven cases) AV Ms. There were no pseudoaneu­ supplying the compartment of the A V M harboring the rysms located in the brain stem. Six of nine pseudoaneurysm was attempted first in every case. Either patients who were not treated immediately had a minitorquer (Nycomed-lngenor, Paris, France) or a pseudoaneurysms that thrombosed sponta­ Tracker (Target Therapeutics, San Jose, CA) catheter with neously. Two other patients of the same group a coaxial 5-F system was used for this purpose. During had pseudoaneurysms that progressively an­ catheter progression into the arterial feeder, injection of nexed to the draining vein, creating a venous contrast material was kept to a minimum. After catheteri - ectasia. All of these eight patients had a favorable 3 18 GARCIA-MONACO AJNR: 14, March/April 1993 * A B c Fig. 2. Case 9. A, CT scan shows intracerebral and intraventricular hemorrhage. B, Intern al carotid angiography (anteroposterior view) performed within 24 hours shows an A
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