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*2. Classification and treatment

The Spetzler-Martin (SM) and Spetzler-Ponce (SP) grading systems [95, 96], as previously described, can be a guide for the therapeutic decision:

2.1. SM Grades 1 (Figure 7) and 2 (Figure 8) or SP Class A:
The treatment of choice is microsurgical resection, but embolization or radiosurgery may be considered as well. In the literature, the risk of morbidity (deficit risk) in the postoperative period ranges from 0.7 to 5% for microsurgery. [25, 32, 92, 95] Whereas preoperative embolization in class A is associated with a fall in the modified ranking Rankin scale (mRS) of up to 16% [106]. Radiosurgery has been related, in some studies, to an increase in the bleeding rate of low grade when compared to high grade [40].

Figure 7a

Grade 1 AVM. a) Cerebral CT showing high density in left frontal lobe.

Figure 7b

Grade 1 AVM. b) Axial cerebral T1-weighted MRI showing flow void corresponding to a left frontal AVM.

Figure 7c

Grade 1 AVM. c) Coronal cerebral T2-weighted MRI showing flow void corresponding to a left frontal AVM.

Figure 7d

Grade 1 AVM. d) Angiography in an antero-posterior (AP) projection showing left frontal AVM fed by left anterior cerebral artery (ACA) branches and draining to the superior sagittal sinus.

Figure 7e

Grade 1 AVM. e) Postoperative angiography in an AP projection showing complete ressection of the AVM.

Figure 7f

Grade 1 AVM. f) Postoperative angiography in an lateral projection showing complete ressection of the AVM.

Figure 8a

Grade 2 AVM. a) Axial cerebral T2-weighted MRI showing flow void corresponding to a left temporal AVM.

Figure 8b

Grade 2 AVM.
b) Computed tomography angiography (CT angiography) showing an AVM fed by a branch of the left posterior cerebral artery (PCA) (arrow 1) and draining to the sigmoid sinus.

Figure 8c

Grade 2 AVM. c) Angiography in a lateral projection showing an AVM fed by a branch of the left PCA.

Figure 8d

Grade 2 AVM. d) Angiography in an AP projection showing an AVM fed by a branch of the left PCA.

Figure 8e

Grade 2 AVM. e) Angiography in a lateral oblique projection showing an AVM fed by a branch of the left PCA and draining to the sigmoid sinus.

Figure 8f

Grade 2 AVM. f) Intraoperative view of the AVM.

Figure 8g

Grade 2 AVM. g) Postoperative angiography of the left internal carotid artery in a lateral projection showing complete ressection of the AVM.

Figure 8h

Grade 2 AVM. h) Postoperative angiography of the left internal carotid artery in an AP projection showing complete ressection of the AVM.

Figure 8i

Grade 2 AVM. i) Postoperative angiography of the left vertebral artery in a lateral projection showing complete ressection of the AVM.

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