Therapeutic Options for Brain Arteriovenous Malformations

The purpose of this review is to provide an overview of brain arteriovenous malformations (AVMs) and focus on their management. The therapeutic options differ in each case depending on the location, size, and adjacent anatomical content of the AVM. The surgical resection by microsurgery is the preferred therapeutic option for a small and superficial AVM not related to an eloquent area (e.g., Spetzler-Martin grades I and II). On the other hand, when facing a very large AVM (e.g., Spetzler-Martin grades IV and V), the conservative and symptomatic treatment remains the most common management option due to the high risk-benefit ratio of any intervention. The management of AVMs with features between these two extremes (e.g., Spetzler-Martin grade III) remains less stablished. Stereotactic radiosurgery usually is the option for deep and small AVMs. Embolization has been usually considered before surgery for occlusion of deep arterial supplies of an AVM or to decrease its nidus size. Young patients and AVMs with compact nidus are features that weight in favor of a surgical approach. For the minority of cases that have the AVM diagnosed before bleeding the most common recommendation is to treat conservatively and particularly to avoid embolization. In summary, surgery is the gold-standard approach to cure an AVM and the choice for small AVMs located in non-eloquent area and with superficial venous drainage; large AVMs are mostly treated conservatively; the treatment of AVM with intermediate features is tailored, chosen with the guidance of classification systems, and encompasses radiosurgery and pre-operative embolization.