Keywords
arteriovenous malformations
microsurgery
radiosurgery
embolization
How to Cite
Abstract
Brainstem arteriovenous malformations (BAVMs) represent one of the most formidable challenges in neurosurgery due to their deep location and proximity to vital centers governing autonomic and motor functions. This review synthesizes current evidence across multiple treatment modalities, including microsurgical resection, stereotactic radiosurgery (SRS), and endovascular embolization. Microsurgery offers immediate, definitive obliteration but is associated with high perioperative morbidity, necessitating the use of advanced neurophysiological monitoring and safe entry zones. SRS has become the primary intervention for deep-seated BAVMs, offering a favorable non-invasive profile despite a multi-year latency period and the risk of radiation-induced changes. Endovascular embolization, while rarely curative in isolation, serves as a critical adjunct for reducing nidal volume or stabilizing high-risk features like intranidal aneurysms. The literature increasingly supports a multimodal approach, tailoring treatment to the unique angioarchitecture of each lesion to optimize functional outcomes. However, the absence of randomized controlled trials and the limitations of traditional grading systems like Spetzler-Martin complicate the establishment of standardized protocols. Technological innovations, particularly Diffusion Tensor Imaging (DTI) and precise radiosurgical delivery systems, have significantly enhanced the safety margins of these interventions. Future research must focus on multicenter longitudinal data and the potential for molecular therapies to stabilize the vascular nidus. This review emphasizes that while BAVM management has evolved significantly, the goal remains a delicate balance between achieving complete obliteration and preserving the intricate neurological integrity of the brainstem, requiring a highly individualized and multidisciplinary strategy.
References
Thines, L., Dehdashti, A. R., Da Costa, L., Tymianski, M., Ter Brugge, K. G., Willinsky, R. A., Schwartz, M., & Wallace, M. (2011). Challenges in the management of ruptured and unruptured brainstem arteriovenous malformations. Neurosurgery, 70(1), 155–161. https://doi.org/10.1227/neu.0b013e31822670ac
Chen, Y., Li, R., Ma, L., Meng, X., Yan, D., Wang, H., Ye, X., Jin, H., Li, Y., Gao, D., Sun, S., Liu, A., Wang, S., Chen, X., & Zhao, Y. (2020). Long-term outcomes of brainstem arteriovenous malformations after different management modalities: A single-centre experience. Stroke and Vascular Neurology, 6(1), 65–73. https://doi.org/10.1136/svn-2020-000407
Han, S. J., Englot, D. J., Kim, H., & Lawton, M. T. (2014). Brainstem arteriovenous malformations: Anatomical subtypes, assessment of “occlusion in situ” technique, and microsurgical results. Journal of Neurosurgery, 122(1), 107–117. https://doi.org/10.3171/2014.8.jns1483
Ghali, G. Z., Ghali, M. G. Z., & Ghali, E. Z. (2018). Endovascular therapy for brainstem arteriovenous malformations. World Neurosurgery, 125, 481–488. https://doi.org/10.1016/j.wneu.2018.08.099
Al-Shalchy, A. K., Al-Khafaji, N. H. A., Alqaraghuli, A. K., & Saad, M. B. (2025). Outcomes and complications of brainstem arteriovenous malformation (AVM) embolization: A systematic review. Cureus, 17(10), e94749. https://doi.org/10.7759/cureus.94749
Yang, W., Porras, J. L., Garzon-Muvdi, T., Xu, R., Caplan, J. M., Hung, A. L., Braileanu, M., Rong, X., Colby, G. P., Coon, A. L., Tamargo, R. J., & Huang, J. (2016). Management outcome of brainstem arteriovenous malformations: The role of radiosurgery. World Neurosurgery, 94, 64–72. https://doi.org/10.1016/j.wneu.2016.06.082
Ai, X., & Xu, J. (2021). The predictors of clinical outcomes in brainstem arteriovenous malformations after stereotactic radiosurgery. Medicine, 100(22), e26203. https://doi.org/10.1097/md.0000000000026203
Solomon, R. A., & Stein, B. M. (1986). Management of arteriovenous malformations of the brain stem. Journal of Neurosurgery, 64(6), 857–864. https://doi.org/10.3171/jns.1986.64.6.0857
Yen, C. P., & Steiner, L. (2011). Gamma knife surgery for brainstem arteriovenous malformations. World Neurosurgery, 76(1–2), 87–95. https://doi.org/10.1016/j.wneu.2011.02.003
Sorenson, T. J., Lanzino, G., Flemming, K. D., Nasr, D. M., Chiu, S. Y., Pollock, B. E., & Brinjikji, W. (2019). Clinical outcome of brainstem arteriovenous malformations after incomplete nidus obliteration. Journal of Clinical Neuroscience, 65, 66–70. https://doi.org/10.1016/j.jocn.2019.03.009
Abecassis, I. J., Xu, D. S., Batjer, H. H., & Bendok, B. R. (2014). Surgical management of brainstem arteriovenous malformations. Neurosurgery Clinics of North America, 25(3), 541–551. https://doi.org/10.1016/j.nec.2014.04.010
Abla, A. A., Nelson, J., Rutledge, W. C., Young, W. L., Kim, H., & Lawton, M. T. (2014). The natural history of aphasia, hemiparesis, and hemianopsia after surgical resection of brain arteriovenous malformations. World Neurosurgery, 82(1-2), 129–133. https://doi.org/10.1016/j.wneu.2013.02.072
Bervini, D., Morgan, M. K., Ritson, E. A., & Heller, G. (2014). Surgery for brainstem arteriovenous malformations: Risk analysis and outcome. Journal of Neurosurgery, 121(1), 101–111. https://doi.org/10.3171/2014.3.jns131653
Da Costa, L., Wallace, M. C., Ter Brugge, K. G., & Tymianski, M. (2009). The natural history and predictive features of hemorrhage from brainstem arteriovenous malformations. Neurosurgery, 65(3), 471–476. https://doi.org/10.1227/01.neu.0000350860.01509.8c
Dumont, T. M., Kan, P., Mokin, M., & Levy, E. I. (2015). A proposed grading system for endovascular treatment of cerebral arteriovenous malformations: Buffalo score. Surgical Neurology International, 6(1), 3. https://doi.org/10.4103/2152-7806.148530
Essayed, W. I., Zhang, F., Unadkat, P., Cosgrove, G. R., Golby, A. J., & O'Donnell, L. J. (2017). White matter tractography for neurosurgical planning: A topography-based review of the current state of the art. NeuroImage: Clinical, 15, 659–672. https://doi.org/10.1016/j.nicl.2017.06.011
Gross, B. A., & Du, R. (2013). Natural history of cerebral arteriovenous malformations: A meta-analysis. Journal of Neurosurgery, 118(3), 437–443. https://doi.org/10.3171/2012.10.jns121280
Hafez, A., Koroknay-Pál, P., Oulasvirta, E., Elseoud, A. A., Lawton, M. T., Niemelä, M., & Laakso, A. (2018). The application of the novel grading scale (Lawton-Young grading system) to predict the outcome of brain arteriovenous malformation. Neurosurgery, 84(2), 529–536. https://doi.org/10.1093/neuros/nyy153
Hartmann, A., Mast, H., Mohr, J. P., Koennecke, H. C., Osipov, A., Pile-Spellman, J., & Stapf, C. (1998). Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation. Stroke, 29(12), 2531–2534. https://doi.org/10.1161/01.str.29.12.2531
Janicijevic, A., Radisavljevic, M., & Stojanovic, N. (2025). Microsurgical resection of unruptured brain arteriovenous malformations: A 12-year single-center experience. Medicina, 61(11), 1993. https://doi.org/10.3390/medicina61111993
Kim, E. J. (2016). A review of cerebral arteriovenous malformations and treatment with stereotactic radiosurgery. Translational Cancer Research, 5(S3). https://doi.org/10.21037/tcr.2016.08.01
Kim, H., Abla, A. A., Nelson, J., McCulloch, C. E., Bervini, D., Morgan, M. K., & Lawton, M. T. (2015). Validation of the supplemented Spetzler-Martin grading system for brain arteriovenous malformations in a multicenter cohort of 1009 surgical patients. Neurosurgery, 76(1), 25–33. https://doi.org/10.1227/neu.0000000000000557
Lawton, M. T., Kim, H., McCulloch, C. E., Michalak, G. J., & Young, W. L. (2010). A supplementary grading scale for resection of brain arteriovenous malformations. Neurosurgery, 66(4), 702–713. https://doi.org/10.1227/01.neu.0000367555.16733.e1
Le, N., Nguyen, H., & Pham, T. (2024). Arteriovenous malformations (AVMs): Molecular pathogenesis, clinical features, and emerging therapeutic strategies. Journal of Personalized Medicine, 14(12), 1273. https://doi.org/10.3390/jpm14121273
Liu, A. S., Li, Y., Ma, L., Wang, S. Z., & Zhao, Y. L. (2014). Clinical features and surgical treatment of brainstem arteriovenous malformations. Chinese Medical Journal, 127(10), 1848–1852.
Magid-Bernstein, J., Girard, R., Polster, S., Srinath, A., Romanos, S., Awad, I. A., & Sansing, L. H. (2022). Cerebral hemorrhage: Pathophysiology, treatment, and future directions. Circulation Research, 130(8), 1204–1229. https://doi.org/10.1161/CIRCRESAHA.121.319949
Massoud, T. F., & Hademenos, G. J. (1999). Brain arteriovenous malformations: Evolution of the modern therapeutic paradigm. Journal of Clinical Neuroscience, 6(5), 373–383. https://doi.org/10.1016/S0967-5868(99)90001-2
Mohr, J. P., Parides, M. K., Stapf, C., Moquete, E., Moy, C. S., Overbey, J. R., & ARUBA Investigators. (2014). Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): A multicentre, non-blinded, randomised trial. The Lancet, 383(9917), 614–621. https://doi.org/10.1016/s0140-6736(13)62302-8
Nikolaev, S. I., Vetiska, S., Bonilla, X., Boudreau, E., Jauhiainen, S., Rezai Jahromi, B., & Radovanovic, I. (2018). Somatic activating KRAS mutations in arteriovenous malformations of the brain. New England Journal of Medicine, 378(3), 250–261. https://doi.org/10.1056/nejmoa1707074
Ogilvy, C. S., Stieg, P. E., Awad, I., Brown, R. D., Jr, Kondziolka, D., Rosenwasser, R., & Young, W. L. (2001). Recommendations for the management of intracranial arteriovenous malformations: A statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke, 32(6), 1458–1471. https://doi.org/10.1161/01.str.32.6.1458
Ondra, S. L., Troupp, H., George, E. D., & Schwab, K. (1990). The natural history of symptomatic arteriovenous malformations of the brain: A 24-year follow-up assessment. Journal of Neurosurgery, 73(3), 387–391. https://doi.org/10.3171/jns.1990.73.3.0387
Pinkiewicz, Mi., Pinkiewicz, Ma., Walecki, J., & Zawadzki, M. (2022). State of the art in the role of endovascular embolization in the management of brain arteriovenous malformations—A systematic review. Journal of Clinical Medicine, 11(23), 7208. https://doi.org/10.3390/jcm11237208
Pollock, B. E., Gorman, D. A., & Schomberg, P. J. (2004). The natural history of unresected intracranial arteriovenous malformations: Analysis of 188 nidal-years of follow-up. Neurosurgery, 54(6), 1328–1333. https://doi.org/10.1227/01.neu.0000124481.56450.93
Richter, H. P. (1983). Arteriovenous malformations of the brain stem. Neurosurgical Review, 6(1), 117–123. https://doi.org/10.1007/BF01784112
Rutledge, W. C., Abla, A. A., Nelson, J., Halbach, V. V., Kim, H., & Lawton, M. T. (2014). Risk factors for hemorrhage during the latency period after gamma knife radiosurgery for brain arteriovenous malformations. Journal of Neurosurgery, 121(Suppl 2), 110–117. https://doi.org/10.3171/2014.7.gks141380
Sahlein, D. H., Mora, P., Becske, T., Huang, P., Jafar, J. J., Connolly, E. S., & Nelson, P. K. (2014). Features predictive of brain arteriovenous malformation hemorrhage: Extranidal aneurysms and venous outflow obstruction. Stroke, 45(6), 1634–1639. https://doi.org/10.1161/strokeaha.114.004923
Schimmel, K., Ali, M. K., Tan, S. Y., Cassis, J., Seltman, J., & Lawton, M. T. (2021). Arteriovenous malformations—Current understanding of molecular pathology and genetics. Frontiers in Neurology, 12, 676107. https://doi.org/10.3389/fneur.2021.676107
Spetzler, R. F., & Martin, N. A. (1986). A proposed grading system for brain arteriovenous malformations. Journal of Neurosurgery, 65(4), 476–483. https://doi.org/10.3171/jns.1986.65.4.0476
Stapf, C., Mast, H., Sciacca, R. R., Choi, J. H., Khaw, A. V., Connolly, E. S., & Mohr, J. P. (2006). Predictors of hemorrhage in patients with untreated brain arteriovenous malformations. Neurology, 66(9), 1350–1355. https://doi.org/10.1212/01.wnl.0000210524.68507.87
Van Beijnum, J., van der Worp, H. B., Schippers, H. M., van Nieuwenhuizen, O., Kappelle, L. J., Rinkel, G. J., & Algra, A. (2011). Familial and non-familial brain arteriovenous malformations: A systematic review and meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry, 82(3), 282–288. https://doi.org/10.1136/jnnp.2010.215574
Wu, J., Srivatsan, A., Carlson, A. P., & Lawton, M. T. (2020). Management of brainstem arteriovenous malformations: A review. Neurosurgical Review, 43(6), 1435–1446. https://doi.org/10.1007/s10143-020-01258-0
Zyck, S., & Gould, G. C. (2024). Arteriovenous malformations of the central nervous system. In StatPearls. StatPearls Publishing.