Management of brain arteriovenous malformations: Still a long and winding road ahead.

In this issue of Neurology ®, a group of authors publish an abundantly referenced review of brain arteriovenous malformations (bAVMs).1 In this review, different grading scales are described in detail and major emphasis is given to different options for interventional management. The discussion of current concepts of pathobiology include passing reference to former claims of progressive neurologic deficits and cerebral steal. Brief sections of the article discuss risk factors for hemorrhage, leading with venous obstruction and deep venous drainage, these exceeding lesion size and location. Seizures and headache are reviewed both as risk factors for hemorrhage and as outcomes from interventions. The review includes a lengthy critique focused on studies of those not having bled: the population-based Scottish Audit of Intracranial Vascular Malformations (SAIVM) and A Randomized Trial of Unruptured Brain Arterial Malformations (ARUBA). No management algorithm is provided, emphasizing the complexity of treatment, given the many variables to be considered beyond just dichotomizing into ruptured vs unruptured.