Diagnostic and therapeutic dilemmas of asymptomatic intracranial AVMs: A case report and evidence-based review.

First described by Virchow in the 19th century, intracranial arteriovenous malformations (AVMs) are complex, tangle-shaped vascular lesions with a number of associated neuroparenchymal, hemodynamic, and angio-architectural changes. However, the clinical description of extracranial AVMs dates back to the Ebers Papyrus (c. 1500 BC), with a still unknown definitive underlying etiology thus far. AVMs are rare lesions, with approximately 0.15% incidence and 0.001-0.5% prevalence, but of high importance as they tend to affect young patients who are frequently otherwise healthy. In the majority of cases, AVMs present as sudden intracranial hemorrhages that require immediate intervention, but incidentally-detected unruptured AVMs are only found in ∼15% of cases, leaving a confusing dilemma regarding the appropriate next step, particularly given the several therapeutic interventions available and clinical trials that were vulnerable to follow-up criticism. Herein, we present a case of an incidentally detected asymptomatic AVM in a 15-year-old boy via advanced imaging techniques that was initially misinterpreted as a post-traumatic subarachnoid hemorrhage on routine imaging studies. In providing a comprehensive overview of pathological classification schemes and the currently available diagnostic options for these silent dilemmatic AVMs, we highlight three management techniques: microsurgical resection, endovascular embolization, and stereotactic surgery, with the best option depends mostly on addressing lesion resection properly with minimal associated mortality and morbidity.