• Marco Cenzato, Fulvio Tartara, Giuseppe D'Aliberti, Carlo Bortolotti, Francesco Cardinale, Gianfranco Ligarotti, Alberto Debernardi, Alessia Fratianni, Edoardo Boccardi, Roberto Stefini, Francesco Zenga, Riccardo Boccaletti, Andrea Lanterna, Giacomo Pavesi, Paolo Ferroli, Carmelo Sturiale, Alessandro Ducati, Andrea Cardia, Maurizio Piparo, Luca Valvassori, and Mariangela Piano.
• Grande Ospedale Metropolitano Niguarda, Milano, Italy; Neurocheeta Discussion Group. Electronic address: marco.cenzato@gmail.com.
• World Neurosurg. 2018 Feb 1; 110: e374-e382.

BackgroundRecent literature strongly challenged indications to perform preventive surgery in unruptured arteriovenous malformation (AVM) claiming that invasive AVM treatment is associated with a significant risk of complications and thus conservative management may be a preferable alternative in many patients. On the other hand, the recent improvement of surgical instrumentation and treatment strategies (both surgical and interventional) yielded better outcomes than those achieved only a decade ago. Therefore, even among specialists, a wide variety of opinions, concerning the treatment of unruptured AVM, can be found.MethodsThis multicenter retrospective study analyzes a consecutive series of 545 surgically treated AVMs in 10 different hospitals in Italy.ResultsPatients with AVMs treated after hemorrhage had an unfavorable (modified Rankin Scale score >1) outcome in more than one third (37.69%) of the cases. Conversely, with proper indications, unruptured AVMs treated preventively have a good outcome in 93.8% of cases, increasing to 95.7%, with no death, if only Spetzler-Martin grades 1-3 are considered (P < 0.05). Outcomes on discharge significantly (P < 0.05) improve at 6 months with the disappearance of many of the initial neurologic deficits that turn out to be transient.ConclusionsIn unruptured low-risk AVMs (Spetzler-Martin grades 1-3), over time, the risk of surgery-associated neurologic deficits becomes lower than that linked to spontaneous hemorrhage, with a crossover point at 6.5 years. Because the average bleeding age is less than 45 years, preventive surgery can be advocated to safeguard the patient and overcome the risks associated with the natural history of AVMs.Copyright © 2017 Elsevier Inc. All rights reserved.

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