Treatment of Intracerebral Vascular Malformations: When to Intervene

Purpose of review: This review highlights the complexity of intracranial vascular malformations and the importance of a multidisciplinary approach for management as it drastically changes from one patient to another and from one lesion to another. We talk about different types of malformations and different management strategies for each lesion. Recent findings: Brain arteriovenous malformations remain a challenging entity for neurosurgeons to this day. The ARUBA trial favored conservative and medical management over intervention, but it had many limitations and was met with criticism. Following diagnosis, brain AVMs are graded based on specific criteria and a risk–benefit assessment for treatment is done. Based on AVM and patient characteristics, either conservative management and observation (higher-grade AVMs) or intervention (lower-grade AVMs) is recommended. Treatment options available include microsurgical resection, endovascular embolization, stereotactic radiosurgery, or any combination of these. No two AVMs are managed the same way, and this review will discuss in detail the specifics for each strategy. We also discuss dural arteriovenous fistulas; they are managed like AVMs, but as opposed to AVMs, higher-grade lesions should be treated while lower-grade ones are observed. Summary: Brain AVMs or dural AVFs can lead to intracranial hemorrhage with catastrophic consequences. As such, many treatment strategies have been developed to help mitigate this risk. However, management is unique to every patient and lesion and thus, personalized, and tailored medicine is essential to achieve the best patient outcomes at the minimum risk possible.