Coexistence of a Hemispheric Developmental Venous Anomaly and Two Ipsilateral Arteriovenous Malformations: A Rare Neurovascular Association

Although developmental venous anomalies (DVAs) are commonly associated with cavernous malformations, their coexistence with arteriovenous malformations (AVMs) remains rare. The presence of multiple AVMs associated with a large hemispheric DVA is exceptional and raises important diagnostic and therapeutic considerations. We present a rare case of this association and discuss its imaging features and clinical implications in light of the existing literature. A 62-year-old patient presented with right upper limb tremor and memory disturbances. Magnetic resonance angiography revealed a right hemispheric DVA with suspicion of an associated frontal AVM. Digital subtraction angiography confirmed a large right hemispheric DVA associated with two ipsilateral AVMs: a right frontal AVM (Spetzler-Martin grade I) and a right paracentral AVM (grade III), harboring a small intranidal arterial aneurysm. An additional saccular aneurysm arising from the right pericallosal artery was also identified. The patient declined treatment and was managed conservatively. During follow-up, intermittent headaches occurred; emergency CT angiography showed no hemorrhage and stable findings, supporting continuation of the surveillance strategy. This rare association highlights the complexity of mixed cerebrovascular malformations. Multimodal imaging, particularly digital subtraction angiography (DSA), is essential for accurate diagnosis and risk assessment. Management should be individualized, with strict preservation of DVA venous drainage to avoid severe complications.