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(Stroke. 2007;38:3308.)
© 2007 American Heart Association, Inc.

Controversies in Stroke

Unruptured Brain Arteriovenous Malformations Should Be Treated Conservatively

Yes

From the Department of Neurology (C.S.), Hôpital Lariboisière, Paris, France; and the Doris and Stanley Tananbaum Stroke Center/The Neurological Institute (C.S., J.P.M.), Columbia University, New York, NY, USA.

Correspondence to Christian Stapf, MD, Department of Neurology, Hôpital Lariboisière, 2, Rue Ambroise Paré, 75475 Paris cedex 10, France. E-mail christian.stapf@lrb.aphp.fr

Geoffrey A. Donnan MD, FRACP Stephen M. Davis MD, FRACP Section Editors

Key Words: AVM • treatment

An extract of the first 250 words of the full text is provided, because this article has no abstract.

In the past, most brain arteriovenous malformations (AVMs) announced their presence by hemorrhage (70% at diagnosis), sometimes devastating, with important long-term morbidity and elevated case-fatality (combined 10-year morbidity and mortality: 27%).¹ Such figures seemed ample justification for any invasive treatment attempt, either partially or in toto. However, these assumptions are largely based on data from the pre-CT era and have now been challenged by the increasing availability of noninvasive brain imaging, especially MRI, which have yielded both a large percentage of unbled lesions in ongoing population-based studies, and low rates of hemorrhage in outcome data from systematic prospective follow-up series.

Brain AVMs are diagnosed more commonly than previously assumed. Current detection rates range from 1.1 to 1.3 per 100 000 patient-years depending on the availability of MR brain imaging.^2,3,4 More important, the prospective New York Islands AVM Study found unruptured AVMs exceeded those ruptured almost twice as often.⁴

Similar to intracranial aneurysms, the natural history of unruptured AVMs seems more favorable than for those discovered after initial hemorrhage. The average risk of bleeding from an unruptured AVM (1.2% per year) seems to be about 5 times lower as compared with already ruptured malformations (5.6% per year).^5,6 The bleeding risk seems to be particularly low in the most frequent subgroup of patients harboring lobar AVMs with superficial venous drainage (0.9% per year).⁶ Finally, although some instances of AVM rupture may indeed be disastrous, there seems to be a far lower morbidity and mortality than after intracerebral bleeding from other causes.⁷

AVM-specific . . . [Full Text of this Article]