Decision Analysis for Symptomatic Lesions

Intracranial AVMs (iAVMs) are rare, complex vascular lesions that pose multiple therapeutic challenges. Patients with iAVMs most commonly present with intracerebral hemorrhage, although they may also present with seizures, neurologic deficits, cognitive changes, or headaches. The ideal treatment strategy for symptomatic iAVMs remains elusive, but recent insights into the natural history of AVMs and rapid advancements in imaging and therapeutic technologies have significantly improved the diagnosis and clinical management of symptomatic lesions. Treatment options include microsurgical resection, radiosurgery, and endovascular embolization. In the nonacute setting, validated classification schemes such as the Spetzler-Martin grading scale are valuable for risk stratification and treatment selection. In the setting of acute rupture, unstable patients with significant mass effect can benefit from emergent hematoma evacuation with or without AVM excision. In most cases, however, delayed definitive treatment is recommended to minimize surgical and neurologic morbidities..