Only 8–12% of intracranial aneurysm and 5–15% of arteriovenous malformations (AVMs) occur in the posterior circulation (1, 2). The association between an AVM and aneurysm of the same artery is a well-known phenomenon, reported in 2.8–9.3% of all AVMs (3). Notably, posterior fossa AVM’s have an increased tendency to develop associated aneurysms compared to AVMs of the anterior circulation (2), and mostly involve the posterior inferior cerebellar artery. The involvement of the anterior inferior cerebellar artery (AICA) is extremely rare (2). Reviewing the literature, only 16 cases of coincident AICA aneurysm and AVM have previously been reported (1, 3–9). Proximal aneurysms, exactly as the index case of this study, occurred in only four cases (7–9).

Herein, we describe an extremely rare case of a cerebellar AVM supplied by the AICA and a proximal aneurysm fed by the same artery, which was managed completely using an endovascular approach. In contrast, all previously reported cases with similar lesion complex were managed surgically. This study provides justifications why endovascular approach was chosen. We also provide a comprehensive review of similar cases reported in the literature.

This study has been approved by the independent ethics committee (Institutional Review Board) at the King Abdullah International Medical Research Center—Jeddah, Saudi Arabia. A written informed consent was obtained from the index case of this study to participate and publish the paper once the study is done. All related information utilized in this paper was obtained through chart review, patient history, and clinical examination.

A 59-year-old Saudi woman presented with a deteriorated level of consciousness after 2 days of severe headaches and multiple episodes of vomiting. A non-enhanced brain CT scan showed a subarachnoid hemorrhage (SAH) (Hunt and Hess grade 4–5), intraventricular hemorrhage, and generalized brain edema (Figure 1). Angiographic series delineated a cerebellar AVM with a nidus of 14 mm × 20 mm in diameter, situated on the post meatal segment of AICA and draining superficially into the transverse sinus (Spetzler–Martin grade II). The nidus was primarily supplied by the AICA, which developed a pre-nidal saccular aneurysm measuring 7 mm × 3 mm (Figure 2). The aneurysm was the source of bleeding.

Considering the size and the proximal location of the aneurysm, along with the low grade of the AVM, as well as the generalized brain edema and SAH, an endovascular approach was decided. The aneurysm was accessed using a 5-French wire-guided catheter inserted, within a 6-French sheath, into the right femoral artery and progressed under fluoroscopy road-map guidance. Coiling of the aneurysm was achieved using three platinum-made, detachable coils (3 mm × 8mm, 2 mm × 8mm, 1.5 mm × 4mm). During the same procedure, the distally located AVM was embolized using a liquid-based suspension consisting of Ethylene–Vinyl–Alcohol copolymers (ONYX), applied through a micro-catheter (APOLLO 38), with a 5-cm detachable tip. Seventy percent of the AVM was obliterated initially and then completed after 6 months. The final series of X-Ray (Figure 3) confirmed the proper positioning of the coils within the aneurysmal sac and occlusion of the AVM. The patient recovered well upon rehabilitation with no evidence of rebleeding or focal neurological deficits at 6-month follow-up. She is fully mobile and independent with a Glasgow outcome score of 4–5.

To the best of our knowledge, this study is the first report describing a proximal AICA aneurysm and AVM treated by endovascular means. The outcome was highly promising, considering the technically demanding location and the complexity of the target lesions. In comparison, all previously reported cases with exactly similar lesions were managed surgically, with inconclusive outcomes. A collaboration of a multi-disciplinary team, including a neurosurgeon, an interventional radiologist, intensivists, and physiotherapists, is highly suggested, with potential impact on the outcome. The results of the reported case are meant to help in the decision-making process for similar cases till more data are available on this rare occasions.

This study was carried out in accordance with the recommendations of “King Abdullah International Medical Research Center” with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the “independent ethics committee (Institutional Review Board—IRB) at the King Abdullah International Medical Research Center (KAIMRC)—Jeddah, Saudi Arabia.”

All authors of this manuscript have actively participated in data acquisition of this paper and they all revise and approve the final form of this paper. They are also responsible for the accuracy and integrity of this work. HK and RS participated in the design of the study. FA and AA did work on the interpretation of the data.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.