Submit Manuscript | http://medcraveonline.com Abbreviation: AVM, arterio-venous malformation; CT, computed tomography; GCS, glasgow coma scale; HA, hemodynamic aneurysm; IEL, internal elastic lamina; MCA, middle cerebral artery; MRI, magnetic resonance imaging Introduction The co-existence of Hemodynamic aneurysm (HA) and Arterio- venous malformation (AVM) is frequently reported in the previous literature by several authors. 2–9 Several theories have been proposed to explain the pathogenesis of these dual pathologies and classifed them according to the topographic relationship of the aneurysm with the nidus Table 1. Perata et al. 2 showed that HAs are mostly present on AVM feeding vessels rather than on other intracranial vessels (11.2% vs. 0.8%). HA is considered as an acquired pathology which serves as a marker of hemodynamic disturbances induced by AVM nidus. The natural history of these dual pathology showed that, aneurysms over time can regress, remain unchanged, can grow, even rupture or may appear at new locations as well. 8 In our reported case, patient had cortical AVM with proximal fow related saccular aneurysm, for which he underwent clipping of the aneurysm in the frst sitting followed by excision of AVM with evacuation of the hematoma in the next sitting and achieved favorable outcome. Case report History and physical examination A 48years old, normotensive non diabetic male presented with sudden onset of severe headache followed by loss of consciousness for 4 hours. He was immediately hospitalized. Admission GCS was E2V2M4. There was anisocoria, whereas right pupil was 5mm, sluggish reacting to light. Left pupil was 4mm and normal reacting to light. Plantar response was bilaterally extensor. However, vital signs were within normal limit. Other systemic examination revealed no abnormalities. This 39-year-old man appeared to be perfectly. Investigations After hospitalization, an urgent CT scan of brain did, which revealed massive hematoma occupying the right sylvian fssure and adjacent parietal lobe (Figure 1). MRI of brain showed T1WI heterogeneously hyper intense lesion present within the right sylvian cistern and adjacent temporo-parietal area. The lesion had multiple intrinsic fow voids in T2WI (Figure 2). Due to initial presentation as intracranial hemorrhage and presence of multiple fow voids in T2WI, a CT angiogram of cerebral vessels was done to sort out the pattern of vascular pathology. CT angiogram showed a saccular J Neurol Stroke. 2019;9(4):189‒194. 189 © 2019 Ansari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Co-existence of arterio-venous malformation and saccular bifurcation aneurysm of a 48years old patient, presented with massive intracranial hemorrhage: case report Volume 9 Issue 4 - 2019 Ayub Ansari, Asifur Rahman, NazminAhmed, ABM Manwar Hossain, Soumen Samadder, Mohammad Samsul Arifn, Robert Ahmed Khan, ASM Abu Obaida, Mohtasimul Hasan, Bipin Chaurasia Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Bangladesh Correspondence: : Bipin Chaurasia, chief resident, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, Tel +8801732531039, Email Received: April 24, 2019 | Published: July 12, 2019 Abstract Background: Hemodynamic aneurysm (HA) associated with arterio-venous malformation (AVM) is considered as one of the risk factors for intracranial hemorrhage. 1,2 Aneurysm appears as a consequence of disruption in the cerebral auto regulatory mechanism which is induced by AVM. According to the previously reported literature, untreated HA after AVM exclusion can regress, remain unchanged, grow or rupture. 1–4 Aim of the work: The aim of this case report is to describe a rare case of simultaneous presence of cortical arterio-venous malformation and saccular bifurcation aneurysm of a 48years old patient for which he underwent clipping of aneurysm and total excision of AVM in two sitting within very short interval of time and achieved favorable outcome. Case report: A 48-year-old normotensive, non-diabetic male presented with sudden onset of severe headache followed by loss of consciousness. After thorough radiological evaluation, he diagnosed as a case of right sided MCA bifurcation aneurysm and small cortical parietal AVM. At frst sitting, he underwent right sided pterional craniotomy and clipping of the aneurysm. 5days later he underwent right parietal craniotomy, evacuation of hematoma and total excision of AVM. His post-operative period was satisfactory and was released from hospital without having any neurological defcit. Conclusion: Proper pre-operative work up, including angiogram should be done for any suspected vascular lesion. Considering the management of our reported case, Author recommends the simultaneous treatment of AVM and HA, which would be most benefcial to the patient. Keywords: aneurysm, arterio-venous malformation, hemodynamic instability Journal of Neurology & Stroke Case Report Open Access