Abstract
INTRODUCTION/PURPOSE: Brain arteriovenous malformations (AVMs) are occasionally associated with flow‐related aneurysms, which complicate treatment strategies and increase the risk of aneurysm rupture. Reports of AVMs with more than six aneurysms are extremely rare. We report here the first case of a cerebellar AVM associated with eight distal flow‐associated aneurysms. We present a successfully treated case using a staged approach combining endovascular embolization and microsurgical resection. MATERIALS AND METHODS: A 59‐year‐old woman presented with sudden headache and vomiting. Brain computed tomography showed a right cerebellar hemorrhage with subarachnoid extension. Digital subtraction angiography (DSA) revealed a Spetzler‐Martin grade II AVM in the right cerebellar hemisphere, supplied by the right posterior inferior (PICA) and superior cerebellar arteries (SCA), accompanied by eight flow‐related aneurysms (Figures A, B).On day 2 after onset, the SCA aneurysm suspected to be the source of the bleeding was embolized with coils, followed by 33% n‐butyl‐2‐cyanoacrylate (NBCA). On day 36, endovascular embolization using Onyx 18 was performed to occlude an SCA feeder considered difficult to access surgically, successfully obliterating one associated aneurysm. Additional embolization of other SCA feeders with 33% NBCA and a small PICA feeder with coils was also performed. Preoperative three‐dimensional fusion imaging was generated using multimodal angiographic datasets to clarify the spatial relationship between the AVM, aneurysms, and cerebellar surface, aiding surgical planning (Figure C).On day 38, AVM resection was performed via suboccipital craniotomy in a hybrid operating room. Several aneurysms were directly visualized on the cerebellar surface (Figure D). After proximal clipping of the two main PICA feeders, circumferential dissection of the nidus was carried out. Two aneurysms were resected with the nidus, and one was surgically clipped. Intraoperative DSA and indocyanine green angiography revealed no residual flow in the remaining three aneurysms. RESULTS: Postoperative imaging revealed no evidence of infarction or residual AVM. The patient was discharged without new neurological deficits, with a modified Rankin Scale score of 2. Follow‐up DSA at 12 months confirmed complete obliteration of the AVM and all eight aneurysms (Figures E, F). CONCLUSION: The present report suggests that even a cerebellar AVM associated with as many as eight flow‐related aneurysms can be successfully treated using a staged, multimodal strategy. A hybrid operating room enabled real‐time intraoperative assessment and adaptation, while preoperative 3D fusion imaging facilitated precise surgical targeting. Careful planning, selective embolization, and image‐guided resection achieved complete lesion eradication with preservation of neurological function. [Image: see text]