Journal of Neurosurgery. 2026;145(2):443–453
Objective
To compare long-term hemorrhagic stroke and mortality after conservative management, microsurgery, stereotactic radiosurgery or embolization alone in patients with low-grade brain arteriovenous malformations.
Methods
Nationwide multicenter prospective observational cohort of patients with Spetzler-Martin grade I or II AVMs. Outcomes were evaluated according to the initial monotherapy strategy.
Main results
Interventional treatment was associated with lower long-term hemorrhagic risk than conservative management, although outcomes varied according to treatment modality and AVM characteristics. Microsurgery offered immediate obliteration but carried an upfront procedural risk; radiosurgery delayed protection until obliteration, while embolization results were strongly dependent on anatomical selection.
Interpretation
Low-grade AVMs should not be treated as a homogeneous group. The balance between natural-history risk and treatment morbidity depends on presentation, eloquence, venous drainage, patient age and the likelihood of complete obliteration.
Limitations
Despite prospective follow-up, treatment was not randomized. The intervention selected was influenced by anatomy, center experience and clinical presentation, leaving a substantial risk of confounding by indication.
Clinical takeaway
For carefully selected Spetzler-Martin grade I–II AVMs, intervention may provide durable protection, but modality selection should be individualized in a multidisciplinary cerebrovascular team.
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