Safety and Effectiveness of Flow-Diversion for Flow-Related Aneurysms in Patients With Brain Arteriovenous Malformations: A Case Series and Review of Literature.

Background and objectives: Flow-diversion for aneurysm is widely adopted. However, reports on flow-diversion for flow-related aneurysms (FA) in brain arteriovenous malformations (bAVM) are scarce. We aim to introduce our institutional experience in this case series.

Methods: We compiled all patients with bAVMs and FA from an institutional database, among which those treated with flow-diverters were extracted. Patient demographics, clinical presentation, aneurysm, and AVM characteristics were summarized. Management of both FA and bAVM were listed. Associated bleeding with dual antiplatelet therapy, aneurysm and bAVM obliteration, and follow-up hemorrhage of bAVM were reported as outcomes of interest.

Results: From a database of 1066 patients with bAVMs, a total of 5 patients with 7 FAs treated with pipeline embolization device (PED) were included. All aneurysm treatment preceded bAVM management. Spetzler-Martin grades were the following: II (n = 2.40%), III (n = 2.40%), and V (n = 1.20%), among which 1 presented with hemorrhage. Only 2 bAVMs (40%) were treated with radiosurgery, and none were obliterated at last follow-up. A total of 9 aneurysms were identified, with just 7 (77.8%) being flow-related and treated with flow-diversion. Three FA treatments (42.9%) received preprocedural Brilinta + Aspirin, with the rest being Plavix + Aspirin, and none of the bAVMs had ruptured while on dual-antiplatelet therapy. With average follow-up duration of 4.8 years, 85.7% (n = 6) of the treated aneurysms were obliterated at follow-up.

Conclusion: PED use to treat for FAs in bAVMs demonstrated favorable risk profile. The effectiveness of FA obliteration with flow-diversion is also favorable and on par with regular non-bAVM aneurysms. The current data suggest PED as an option to manage FAs in bAVMs.