Endovascular treatment of unruptured Spetzler-Martin grade IV and V brain AVMs in a predominantly Hispanic patient cohort

Background Endovascular embolization (EE) of brain arteriovenous malformations (bAVM) has historically carried high risk and low efficacy. In the setting of improved endovascular devices and embolization techniques this is changing. This is especially important for high grade, unruptured bAVMs as their management remains controversial. Methods This is a single center case series using a prospectively maintained database. Included patients underwent EE with intent to cure of unruptured Spetzler-Martin grade IV or V bAVMs from August 2015 to May 2023. Baseline, clinical and bAVM characteristics were recorded. Outcomes of interest included angiographic cure, intracranial hemorrhage (ICH), persistent neurological deficits (PND), change in baseline functional status and mortality. Results Twelve patients (median 27yo, 50% female, 92% Hispanic) underwent a total of 53 EE. Eight had grade IV and four had grade V bAVM. Median AVM size was 48.6 mm (IQR 44.8–68.1). All patients underwent both transarterial and transvenous embolization. Of the eleven patients who completed treatment, eight achieved angiographic cure with endovascular embolization alone and two with adjunct stereotactic radiosurgery (SRS). One patient experienced intraprocedural microwire vessel perforation with no associated long-term sequelae. No patient experienced PND or post-procedural ICH. All patients were at their neurological baseline on last follow-up. There were zero mortalities. Conclusion We observed a high rate of angiographic cure, low rate of adverse events and no disability or mortality in patients who underwent EE of high-grade unruptured bAVM. This suggests with improved endovascular capabilities and careful patient selection, endovascular treatment of high-grade AVMs should be considered when clinically indicated.