Palliation Versus Observation: Nonresectable AVMs

Non-resectable intracranial AVMs (iAVMs) pose unique challenges to neurosurgical management, as their location within eloquent regions of the brain, large nidal size, and/or presence of deep venous drainage preclude safe microsurgical resection for cure, while the lesions themselves continue to pose an inherent hemorrhage risk and may produce neurological symptoms. AVM hemorrhage risk must be assessed on a case-by-case basis with the neurointerventionalist giving ample consideration to both the angioarchitectural features of the lesion and the clinical characteristics of the patient. Endovascular therapy may be utilized in appropriately selected patients to occlude high-risk AVM angiographic features in an attempt to reduce lesional hemorrhage risk or to treat symptoms related to intralesional vascular shunting. Alternatively, stereotactic radiosurgery may be used to treat other non-resectable iAVMs with the goal of achieving either cure or symptom palliation. In cases of asymptomatic non-resectable iAVMs that lack high-risk angiographic features, close clinical and radiologic observation may represent viable management strategy..