title: Acute rupture of a feeding artery aneurysm after embolization of a brain arteriovenous malformation.
abstract: BACKGROUND
  Staged endovascular embolization of large arteriovenous malformations (AVMs) is frequently performed to gradually reduce flow and prevent abrupt hemodynamic changes. While feeding artery aneurysms have been associated with increased risk of hemorrhage in the setting of AVMs, decisions regarding if and when to treat these aneurysms vary. Acute, fatal rupture of a feeding artery aneurysm following embolization of a large, unruptured AVM has been infrequently reported in the literature.
  
  
  METHODS
  A 69-year-old female presented with headache and mild left hemiparesis referable to a 5 cm right fronto-parieto-temporal AVM with surrounding vasogenic edema. The AVM was associated with numerous bilateral feeding artery aneurysms (the largest was a 2 cm right middle cerebral artery (MCA) bifurcation aneurysm). There was also a large, partially thrombosed venous varix. Staged embolization of the AVM was performed. Several hours after the third stage of her embolization, she became obtunded, with a fixed and dilated right pupil. Head computed tomography (CT) showed a large intraparenchymal hemorrhage with midline shift in the right sylvian fissure, remote from the AVM nidus. She was taken to surgery for a decompressive craniectomy and hematoma evacuation. The MCA aneurysm was confirmed to be the source of hemorrhage and it was clipped. Despite aggressive medical and surgical treatments, the patient died.
  
  
  CONCLUSIONS
  An increase in AVM feeding artery pressure following endovascular embolization may contribute to the rupture of a feeding artery aneurysm. For this reason, treatment of large arterial aneurysms on feeding pedicles should be considered prior to embolization of the AVM nidus.
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, USA reynoldsm@wudosis.wustl.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, USA.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Arias
authors.affiliation: Department of Radiology, Washington University Medical School, USA.
authors.forename: Arindam R
authors.initials: AR
authors.lastname: Chatterjee
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, USA.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Chicoine
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, USA Department of Radiology, Washington University Medical School, USA.
authors.forename: Dewitte T
authors.initials: DT
authors.lastname: Cross
mesh_terms: D000368:Aged; D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging*; D003937:Diagnosis, Differential; D004621:Embolization, Therapeutic; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging*; D002538:Intracranial Arteriovenous Malformations / Q000628:therapy*; D011183:Postoperative Complications / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed
keywords: Intracerebral aneurysm; arteriovenous malformation; feeding artery aneurysm; onyx embolization; pedicle aneurysm