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Case series
The incidence of infratentorial arteriovenous malformation-associated aneurysms: an institutional case series and systematic literature review
  1. Mark Davison1,
  2. Maximos McCune2,
  3. Nishanth Thiyagarajah2,
  4. Ahmed Kashkoush1,
  5. Rebecca Achey1,
  6. Michael Shost3,
  7. Gabor Toth2,
  8. Mark Bain1,2,
  9. Nina Moore1,2,4
    1. 1Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
    2. 2Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
    3. 3Case Western Reserve University School of Medicine, Cleveland, OH, USA
    4. 4Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
    1. Correspondence to Dr Mark Davison, Neurological Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA; davisom{at}


    Background Arteriovenous malformation (AVM)-associated aneurysms represent a high-risk feature predisposing them to rupture. Infratentorial AVMs have been shown to have a greater incidence of associated aneurysms, however the existing data is outdated and biased. The aim of our research was to compare the incidence of supratentorial vs infratentorial AVM-associated aneurysms.

    Methods Patients were identified from our institutional AVM registry, which includes all patients with an intracranial AVM diagnosis since 2000, regardless of treatment. Records were reviewed for clinical details, AVM characteristics, nidus location (supratentorial or infratentorial), and presence of associated aneurysms. Statistical comparisons were made using Fisher’s exact or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis determined independent predictors of AVM-associated aneurysms. As a secondary analysis, a systematic literature review was performed, where studies documenting the incidence of AVM-associated aneurysms stratified by location were of interest.

    Results From 2000–2024, 706 patients with 720 AVMs were identified, of which 152 (21.1%) were infratentorial. Intracranial hemorrhage was the most common AVM presentation (42.1%). The incidence of associated aneurysms was greater in infratentorial AVMs compared with supratentorial cases (45.4% vs 20.1%; P<0.0001). Multivariable logistic regression demonstrated that infratentorial nidus location was the singular predictor of an associated aneurysm, odds ratio: 2.9 (P<0.0001). Systematic literature review identified eight studies satisfying inclusion criteria. Aggregate analysis indicated infratentorial AVMs were more likely to harbor an associated aneurysm (OR 1.7) and present as ruptured (OR 3.9), P<0.0001.

    Conclusions In this modern consecutive patient series, infratentorial nidus location was a significant predictor of an associated aneurysm and hemorrhagic presentation.

    • Arteriovenous Malformation
    • Aneurysm
    • Posterior fossa
    • Angiography
    • Hemorrhage

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    • Contributors All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by MD, MM, and NT. Manuscript preparation was performed by MD and all authors participated in manuscript revisions. All authors reviewed and approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.