Treatment Strategies for Feeder Artery Aneurysms Associated With Arteriovenous Malformations

BACKGROUND AND OBJECTIVES: Intracranial arterial aneurysms are frequently discovered in the presence of cerebral arteriovenous malformations (AVMs). The presence of both a feeder artery aneurysm (FAA) and an AVM is associated with a more aggressive clinical course. This study aimed to describe a single-center experience treating AVM-associated FAAs over a two-decade period and review multimodality treatment strategies in both ruptured and unruptured presentations. METHODS: A retrospective review was conducted of patients (18 years and older) who presented with an AVM and one or more associated FAAs between January 2000 and December 2025. Intranidal aneurysms and aneurysms unrelated to the AVM were excluded. Angiographic follow-up of at least 30 days was required for inclusion in outcome analysis. Data on AVM and FAA characteristics, treatment strategies, and outcomes were collected and analyzed. RESULTS: A total of 81 patients with 82 AVMs and 132 FAAs were identified. Most AVMs were supratentorial (63.4%), with 70.7% presenting with intracranial hemorrhage originating from either the AVM nidus or an associated FAA. Of the 60 FAAs with ≥30-day follow-up, 42 were directly treated, and 95% (40/42) achieved complete occlusion. Occlusion rates were 100% for microsurgical clipping/resection and n-butyl cyanoacrylate embolization, and 80% for endovascular coiling. Among 18 untreated FAAs with follow-up, 12 regressed after treatment of the underlying AVM and 6 remained stable. No untreated aneurysm enlarged or ruptured. The overall rate of symptomatic complication after FAA treatment was 5.5% (4/73), with no treatment-related mortality. CONCLUSION: AVM-associated FAAs can be managed with multimodal strategies that yield high occlusion rates and with a low risk of complications. In select cases, FAAs may regress after treatment of the underlying AVM, suggesting that not all lesions require direct intervention. These findings support an individualized approach to management and provide a foundation for future prospective studies to refine treatment plans.