Multi-Modality Treatment for Intracranial Arteriovenous Malformation Associated with Arterial Aneurysm

OBJECTIVE: Intracranial arteriovenous malformation (AVM) associated with aneurysm has been infrequently encountered and the treatment for this malady is challenging. We report here on our clinical experience with AVMs associated with arterial aneurysms that were managed by multimodality treatments, including clipping of the aneurysm, microsurgery, Gamma-knife radiosurgery (GKS) and Guglielmi detachable coil (GDC) embolization. METHODS: We reviewed the treatment plans, radiological findings and clinical courses of 21 patients who were treated with GKS for AVM associated with aneurysm. RESULTS: Twenty-seven aneurysms in 21 patients with AVMs were enrolled in this study. Hemorrhage was the most frequent presenting symptom (17 patients : 80.9%). Bleeding was caused by an AVM nidus in 11 cases, aneurysm rupture in 5 and an undetermined origin in 1. Five patients were treated for associated aneurysm with clipping followed by GKS for the AVM and 11 patients were treated with GDC embolization combined with GKS for an AVM. Although 11 associated aneurysms remained untreated after GKS, none of them ruptured and 4 aneurysms regressed during the follow up period. Two aneurysms increased in size despite the disappearance of the AVM nidus after GKS and then these aneurysms were treated with GDC embolization. CONCLUSION: If combined treatment using microsurgery, GKS and endovascular treatment can be adequately used for these patients, a better prognosis can be obtained. In particular, GKS and GDC embolization are considered to have significant roles to minimize neurologic injury.

Orbital Solitary Fibrous Tumor : A Case Report and Diagnostic Clues

Orbital solitary fibrous tumor (SFT) is a rare tumor originating from the mesenchyme. We describe the clinical presentations, radiological and operative findings, and pathological features of a patient with orbital SFT. The patient was a 46-year-old female who presented with progressive proptosis advanced for 20 months. On ophthalmological examination, no visual impairment was detected, but left eye was found to be obviously protruded on exophthalmometry. Orbital magnetic resonance imaging showed a 2.5 x 2 x 2 cm, intensely enhanced mass in the left orbit, which compressed the eyeball forward and the optic nerve downward. The patient underwent frontal craniotomy with superior orbitotomy and gross total resection was performed for the tumor. The histopathological diagnosis including immunohistochemistry was a SFT. After the surgery, proptosis was markedly relieved without visual impairment. Although orbital SFT is extremely rare, it should be considered in the differential diagnosis of orbital tumors. Clinical presentations such as painless proptosis and CD34 immunoreactivity play a significant role in differentiating orbital SFT from other spindle-cell neoplasms of the orbit.