first patient was 33-year - old man admitted with generalized tonic - clonic seizure for 5 minutes . a computed tomography ( ct ) demonstrated fisher grade iv sah along the both sylvian fissures , interhemispheric fissure , and dominantly in the premedullary and prepontine cistern and intraventricular hemorrhage in 3rd and 4th ventricles . a digital subtraction angiogram ( dsa ) revealed two left anterior inferior cerebellar artery ( aica ) aneurysms located at the premeatal and meatal branches and two left lateral pontine artery aneurysms and associated avm distal from the aneurysms ( fig . , these aneurysms and avm nidus were embolized with 33% mixture of n - butylcyanoacrylate ( nbca ) and lipiodol ( fig . 1b ) at a same time , and residual avm nidus were treated with stereotactic radiosurgery . 2 years after stereotactic radiosurgery , a small draining vein was remained ( fig . ct scan demonstrated fisher grade iv sah along the both sylvian fissures , basal cistern and intraventricular hemorrhage in 4th ventricle . a dsa revealed three irregular shaped aneurysms located at the meatal , dorsolateral branches of right aica and avm fed by the right aica and right superior cerebellar artery ( fig . we could not differentiate a ruptured pseudoaneurysm from dysplatic true aneurysms , because the shape of those was similar and location was very close each other . on that day , these aneurysms and avm nidus were embolized ( fig . one year after stereotactic radiosurgery , small residual avm nidus and draining vein were noted ( fig . first patient was 33-year - old man admitted with generalized tonic - clonic seizure for 5 minutes . a computed tomography ( ct ) demonstrated fisher grade iv sah along the both sylvian fissures , interhemispheric fissure , and dominantly in the premedullary and prepontine cistern and intraventricular hemorrhage in 3rd and 4th ventricles . a digital subtraction angiogram ( dsa ) revealed two left anterior inferior cerebellar artery ( aica ) aneurysms located at the premeatal and meatal branches and two left lateral pontine artery aneurysms and associated avm distal from the aneurysms ( fig . , these aneurysms and avm nidus were embolized with 33% mixture of n - butylcyanoacrylate ( nbca ) and lipiodol ( fig . 1b ) at a same time , and residual avm nidus were treated with stereotactic radiosurgery . 2 years after stereotactic radiosurgery , a small draining vein was remained ( fig . ct scan demonstrated fisher grade iv sah along the both sylvian fissures , basal cistern and intraventricular hemorrhage in 4th ventricle . a dsa revealed three irregular shaped aneurysms located at the meatal , dorsolateral branches of right aica and avm fed by the right aica and right superior cerebellar artery ( fig . we could not differentiate a ruptured pseudoaneurysm from dysplatic true aneurysms , because the shape of those was similar and location was very close each other . on that day , these aneurysms and avm nidus were embolized ( fig . one year after stereotactic radiosurgery , small residual avm nidus and draining vein were noted ( fig . the occurrence of an intracranial saccular aneurysm of the feeding artery to an avm is a well - known phenomenon ( 2 , 3 ) . the increase of blood flow in a vessel feeding an avm predisposes the development of aneurysm on that vessel . ( 4 , 6 ) reviewed 65 cases of avms that had bled in an attempt to identify which vascular characteristics correlated with past hemorrhage . they identified two types of arterial aneurysms : 1 ) intranidal aneurysms that show a high association with hemorrhage and 2 ) arterial aneurysms in either the circle of willis or an arterial pedicle supplying the avm . perata et al . ( 7 ) attempted to clarify these two classifications , and defined pedicle aneurysms as those along the course of the feeding artery but remote from the circle of willis . they classified the aneurysms as 1 ) dysplastic or remote , unrelated to inflow vessels , 2 ) proximal , arising at the circle of willis origin of a vessel supplying the avm , 3 ) pedicular , arising from the midcourse of a feeding pedicle , and 4 ) intranidal , within the avm nidus itself . they had question whether these pedicle aneurysms are true aneurysms that were present prior to bleeding or pseudoaneurysms developing when a rupture of a weak , thin - walled vessel occurs . in their cases , four patients suffered recurrent hemorrhage before surgery and aneurysm causing hemorrhage was a single one in each cases . but in our cases , the aneurysms on the feeding artery pedicles adjacent to the avm were multiple and patients had no history of previous hemorrhagic event . the differential diagnosis among aneurysms , a true nidal aneurysm , and a pseudoaneurysm is not easy to make except by pathological evidence ( 8 , 9 ) . despite imperfect knowledge of the exact etiology and histology of pedicle aneurysms , these aneurysms are an important subgroup of aneurysms associated with avms and indicate a site of hemorrhage ( 4 , 6 ) . discovery of a pedicle aneurysm should prompt aggressive management of the aneurysm itself with embolization when avm resection must be delayed or when radiosurgery is planned . in our cases , the aneurysms were found in the near the meatal segment of the aica ( 1 in premeatal , 3 in meatal , and 1 in dorsolateral segment ) and proximal pontine artery . ( 10 ) reported that 76.2% of aneurysms of the aica were located in the meatal segment and only 10 of 86 were associated with avms . among three patients who had multiple peripheral aica aneurysms , two were associated with cerebellar avms , and one patient had two aneurysms in the distal dorsolateral branch of the aica . in our cases , 60% of the aneurysms were in meatal segment of aica and we guess these aneurysm formation can be related with turbulent flow by acute angulation of this segment . we suspect one of aneurysms must be pseudoaneurysm due to its association with recent hemorrhage . however , it was not easy to differentiate ruptured pseudoaneurysm from dysplastic flow related true aneurysms . we attempted endovascular embolization with nbca to obliterate all the aneurysms and to restrict avm blood flow at a same time . after control of feeding pedicle having aneurysms , embolization of the other pedicles of avm was done . control of the aneurysms prior to the embolization of avm feeders may avoid the catastrophic consequences of rebleeding . residual avm was amenable to radiosurgery . in conclusion , we experienced two cases of multiple feeding pedicle aneurysms associated with posterior fossa avms presented with a one episode of sah . these patients had no history of previous intracranial hemorrhage but all aneurysms had irregular shape like pseudoaneurysms . embolization of aneurysms and avm nidus with nbca at a same time showed good clinical results . in cases of having remained avm nidus , radiosurgery is recommended to obliterate the residual avm nidus .
we experienced rare combination of multiple irregular shaped aneurysms along the course of the feeding artery and arteriovenous malformation ( avm ) in the posterior circulation . 
 we could not explain which aneurysm was a cause of bleeding because all the aneurysms showed irregular in shape like pseudoaneurysms and location of the aneurysms was very close each other . 
 we report two cases in which multiple irregular shaped aneurysms were related with avms and first episode of hemorrhage .