Combined treatment of high-risk cerebral arteriovenous malformations according to Spetzler-Martin classification

Background. High-risk cerebral AVMs (Spetzler-Martin grade IV—V) are characterized by higher cumulative risk of hemorrhage during life, as well as higher mortality and disability rates in case of rupture compared to low-risk AVMs. Nevertheless, there are currently no clear indications for surgical intervention for high-risk AVMs, and most patients with this disease are followed-up. However, available data on less favorable course of high-risk AVMs requires active surgical tactics to reduce long-term disability and mortality. Currently, the following strategies are preferable for high-risk AVMs: combination of preoperative embolization with microsurgical resection and combination of partial endovascular embolization with subsequent radiosurgery. Objective. To analyze the most common treatment combinations for high-risk AVMs regarding resection quality, functional outcomes and complications. Material and methods. The study was carried out in accordance with international recommendations for systematic reviews and meta-analyses (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Searching was conducted in the Pubmed/Medline and eLibrary databases using the keywords «High grade», «Arteriovenous Malformations», «Management», «IV—V» and «AVM» for English-language search engines, «артериовенозные мальформации высокой степени» for Russian-language systems. Available full-text English-and Russian-language articles were selected between 1981 and 2024. Results. Among 371 articles, 6 studies met the inclusion criteria. There were 478 patients who underwent two most common strategies for combined treatment of high-risk AVMs. Conclusion. At present, there is no consensus on the advantage of certain combined method. There are data on less favorable course of high-grade AVMs and unsatisfactory outcomes after monomodal treatment. Thus, combined methods may be valuable for such AVMs. © 2025 Elsevier B.V., All rights reserved.