Case Report
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Mar 26, 2023; 11(9): 1992-2001
Published online Mar 26, 2023. doi: 10.12998/wjcc.v11.i9.1992
Delayed versus immediate intervention of ruptured brain arteriovenous malformations: A case report
Andi Kurnia Bintang, Ashari Bahar, Muhammad Akbar, Gita Vita Soraya, Anthony Gunawan, Nurussyariah Hammado, Mochammad Erwin Rachman, Zulvikar Syambani Ulhaq
Andi Kurnia Bintang, Ashari Bahar, Muhammad Akbar, Gita Vita Soraya, Anthony Gunawan, Nurussyariah Hammado, Mochammad Erwin Rachman, Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
Gita Vita Soraya, Department of Biochemistry, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia
Nurussyariah Hammado, Faculty of Health and Sport Science, State University of Makassar, Makassar 90222, Indonesia
Mochammad Erwin Rachman, Faculty of Medicine, Muslim University of Indonesia, Makassar 90231, Indonesia
Zulvikar Syambani Ulhaq, Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency Republic of Indonesia, Cibinong 16911, Indonesia
Zulvikar Syambani Ulhaq, Laboratory of Developmental Disorders and Toxicology, Kyushu University, Fukuoka 8190395, Japan
Zulvikar Syambani Ulhaq, Department of Biomedical Science, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University, Malang 65144, Indonesia
Author contributions: Bahar A and Bintang AK conceptualized and supervised the study, performed the data collection and finalized the manuscript; Bahar A, Soraya GV and Bintang AK drafted the manuscript and revised the manuscript; Ulhaq ZS and Soraya GV performed the systematic review; Gunawan A, Akbar M, Hammado N, Rachman ME, and Ulhaq ZS revised the manuscript and provided substantial input; all authors have read and approved the final manuscript.
Informed consent statement: The subject described in the case report has provided written consent for publication.
Conflict-of-interest statement: The authors declare no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Ashari Bahar, MD, Consultant Physician-Scientist, Department of Neurology, Hasanuddin University, Jl. Perintis Kemerdekaan No.KM.10, Makassar 90245, Indonesia.
Received: October 7, 2022
Peer-review started: October 7, 2022
First decision: November 22, 2022
Revised: December 7, 2022
Accepted: February 22, 2023
Article in press: February 22, 2023
Published online: March 26, 2023

Brain arteriovenous malformations (bAVMs) remains one of the most prevalent causes of intracranial hemorrhage and stroke-like syndromes in the young adult population. Although it has been agreed upon that definitive treatment using either single or multi-modal approach is warranted for successful bAVM management, much debate still revolves regarding the optimal timing of definitive treatment.


In this report, we present a case of delayed, definitive endovascular treatment for ruptured bAVM in a 21-year-old female, 3 mo post-ictus. The bAVM, with a left pericallosal feeding artery and cortical draining veins, was successfully obliterated through embolization using the Onyx 18. On follow-up the patient has recommenced her daily activities and experiences only mild occasional headaches with mild motor deficits. The report leads to our review on an important issue regarding the optimal timing of ruptured bAVM definitive management and bring forward the current evidence available on delayed vs immediate definitive bAVM intervention. We also highlight current issues that need to be addressed for clearer guidelines on definitive therapy initiation.


Current treatment paradigms of ruptured bAVM remains elusive, with substantial heterogeneity in the current literature. A consensus on the definition of “acute” vs “delayed”, management goal, follow-up length and outcome parameters are required to support formation of a clear paradigm.

Keywords: Brain arteriovenous malformation, Ruptured brain arteriovenous malformation, Definitive intervention, Endovascular treatment, Case report

Core Tip: In this case report, we present an example of successful delayed management of a ruptured brain arteriovenous malformation (bAVM) in a young female. The case is followed by an updated review regarding current “delayed” and “immediate” definitive interventions for bAVMs and problems associated with the current data on the effectivity of these paradigms.