Anterior Choroidal Artery Aneurysm: Basal Ganglia AVM, Supplied by the Anterior Choroidal Artery, with an Intranidal Aneurysm; Targeted Embolization Prior to Radiosurgery

  • Marta Aguilar PérezEmail author
  • Muhammad AlMatter
  • Marcel Alfter
  • Marc Münter
  • Hans Henkes
Living reference work entry


A 30-year-old male patient presented with a sudden headache, followed by a minor left hemiparesis. Diagnostic imaging revealed a circumscribed right sided thalamic hematoma und an underlying brain arteriovenous malformation (bAVM) supplied by the anterior choroidal artery and perforators of the basilar artery with deep venous drainage. The bAVM nidus consisted of several feeding arteries of small caliber and two draining veins. An aneurysm with a diameter of 3 mm was identified on the posterior aspect of the bAVM nidus. The bAVM was not considered suitable for microsurgical resection due to the location of the nidus. Therefore, stereotactic radiosurgery was considered the most promising treatment strategy. Given the expected latency of 2–3 years between irradiation and bAVM vessel obliteration, the intranidal aneurysm was a concern. It was therefore excluded prior to radiosurgery by embolization using nBCA. The selective catheterization of the bAVM feeding artery carrying the intranidal aneurysm was straightforward. nBCA (Glubran 2, GEM) diluted with ethiodized oil (Lipiodol Ultra-Fluid, Guerbet) was slowly injected through the microcatheter. The solidified polymer cast occluded the intranidal aneurysm as well as the arterial vessel proximal and the transitional vessel segment distal to the aneurysm. The patient tolerated this procedure well and underwent stereotactic irradiation of the bAVM 10 days later. The significance and management of intranidal aneurysms in bAVMs are the main topics of this chapter.


Anterior choroidal artery Arteriovenous malformation Intranidal aneurysm Intracerebral hemorrhage Embolization nBCA Lipiodol Radiosurgery 


  1. Akabane A, Jokura H, Ogasawara K, Takahashi K, Sugai K, Ogawa A, Yoshimoto T. Rapid development of an intranidal aneurysm with perifocal brain edema in an unruptured cerebral arteriovenous malformation. Case report. J Neurosurg. 2002 Dec;97(6):1436–40. Scholar
  2. Al-Shahi R, Fang JS, Lewis SC, Warlow CP. Prevalence of adults with brain arteriovenous malformations: a community based study in Scotland using capture-recapture analysis. J Neurol Neurosurg Psychiatry. 2002 Nov;73(5):547–51.CrossRefGoogle Scholar
  3. Ding D, Xu Z, Starke RM, Yen CP, Shih HH, Buell TJ, Sheehan JP. Radiosurgery for cerebral arteriovenous malformations with associated arterial aneurysms. World Neurosurg. 2016 Mar;87:77–90. Scholar
  4. Gross BA, Du R. Natural history of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg. 2013 Feb;118(2):437–43. Scholar
  5. Le Feuvre D, Taylor A. Target embolization of AVMs: identification of sites and results of treatment. Interv Neuroradiol. 2007 Dec;13(4):389–94. Scholar
  6. Lv X, Wu Z, He H, Ge H, Li Y. Proposal of classification of aneurysms coexisting with AVM and possible treatment strategies. Turk Neurosurg. 2016;26(2):229–33. Scholar
  7. Marks MP, Lane B, Steinberg GK, Snipes GJ. Intranidal aneurysms in cerebral arteriovenous malformations: evaluation and endovascular treatment. Radiology. 1992 May;183(2):355–60. Scholar
  8. Meisel HJ, Mansmann U, Alvarez H, Rodesch G, Brock M, Lasjaunias P. Cerebral arteriovenous malformations and associated aneurysms: analysis of 305 cases from a series of 662 patients. Neurosurgery. 2000;46(4):793–800. Discussion 800–2. Scholar
  9. Mjoli N, Le Feuvre D, Taylor A. Bleeding source identification and treatment in brain arteriovenous malformations. Interv Neuroradiol. 2011 Sep;17(3):323–30. Scholar
  10. Omodaka S, Endo H, Fujimura M, Niizuma K, Sato K, Matsumoto Y, Tominaga T. High-grade cerebral arteriovenous malformation treated with targeted embolization of a ruptured site: wall enhancement of an intranidal aneurysm as a sign of ruptured site. Neurol Med Chir (Tokyo). 2015;55(10):813–7. Scholar
  11. Pollock BE, Flickinger JC, Lunsford LD, Bissonette DJ, Kondziolka D. Hemorrhage risk after stereotactic radiosurgery of cerebral arteriovenous malformations. Neurosurgery. 1996;38(4):652–9. Discussion 659–61. Scholar
  12. Redekop G, TerBrugge K, Montanera W, Willinsky R. Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage. J Neurosurg. 1998 Oct;89(4):539–46. Scholar
  13. Settecase F, Hetts SW, Nicholson AD, Amans MR, Cooke DL, Dowd CF, Higashida RT, Halbach VV. Superselective intra-arterial ethanol sclerotherapy of feeding artery and nidal aneurysms in ruptured cerebral arteriovenous malformations. AJNR Am J Neuroradiol. 2016 Apr;37(4):692–7. Scholar
  14. Stapf C, Mohr JP, Pile-Spellman J, Sciacca RR, Hartmann A, Schumacher HC, Mast H. Concurrent arterial aneurysms in brain arteriovenous malformations with haemorrhagic presentation. J Neurol Neurosurg Psychiatry. 2002 Sep;73(3):294–8. Scholar
  15. van Rooij WJ, Jacobs S, Sluzewski M, Beute GN, van der Pol B. Endovascular treatment of ruptured brain AVMs in the acute phase of hemorrhage. AJNR Am J Neuroradiol. 2012 Jun;33(6):1162–6. Scholar

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© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Marta Aguilar Pérez
    • 1
    Email author
  • Muhammad AlMatter
    • 1
  • Marcel Alfter
    • 1
  • Marc Münter
    • 2
  • Hans Henkes
    • 1
  1. 1.Neuroradiologische KlinikNeurozentrum, Klinikum StuttgartStuttgartGermany
  2. 2.Klinik für Strahlentherapie und RadioonkologieKlinikum StuttgartStuttgartGermany

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