Brain Arteriovenous Malformation (AVM) · Spetzler-Martin Grade and Treatment

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Ruptured? + Spetzler-Martin grade
   Ruptured hemorrhage? Spetzler-Martin grade (size + eloquence + deep venous drainage)? (SM score: nidus size <3/3–6/>6 cm = 1/2/3 points; eloquent location +1; deep venous drainage +1; total grade I–V.)
   • Ruptured hemorrhage → Ruptured → active cure
   • Unruptured, SM I–II (low grade) → Unruptured SM I–II → microsurgery preferred
   • Unruptured, SM III → Unruptured SM III → individualized multimodal
   • Unruptured, SM IV–V (high grade) → Unruptured SM IV–V → mostly conservative
2. [End] Ruptured → active cure
   Ruptured AVM → high rebleeding risk, favor active cure (microsurgery/embolization/SRS or multimodal); choose by SM grade and location, often preoperative embolization to reduce supply before resection; acutely manage the hematoma and raised ICP first, treat the nidus electively.
3. [End] Unruptured SM I–II → microsurgery preferred
   Unruptured SM I–II → microsurgical resection has a high cure rate with acceptable risk, preferred; embolization/SRS also options. Note ARUBA showed intervention for unruptured AVM had higher short-term stroke/death than medical management alone, so individualize, weighing life expectancy against lifetime hemorrhage risk in shared decision-making.
4. [End] Unruptured SM III → individualized multimodal
   Unruptured SM III → highly heterogeneous, individualized multimodal (embolization + surgery or + SRS); weigh treatment risk against lifetime hemorrhage risk, combining location, nidus architecture and patient preference.
5. [End] Unruptured SM IV–V → mostly conservative
   Unruptured SM IV–V → high surgical morbidity/mortality, mostly conservative follow-up, or partial treatment only for high-risk features (associated aneurysm, venous outflow stenosis); after ARUBA, more conservative for unruptured high grades.

Source guidelines & references

• Brain AVM management (Spetzler-Martin grade; ARUBA trial Lancet 2014)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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