Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations

Aug 27, 2026

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Managing patients with unruptured brain aneurysms or brain arteriovenous malformations (AVMs) involves uncertainty because preventive therapy carries treatment-related risks despite relatively low hemorrhage rates. The review summarizes natural history, hemorrhage risk factors, and available preventive treatment options, emphasizing that decisions should weigh patient characteristics, life expectancy, aneurysm anatomy, and procedural risk. Recent developments include ongoing randomized trials, higher flow-diversion obliteration rates, and trial data suggesting greater morbidity and mortality with interventional treatment for AVMs.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages21

Reading Time53 min

AccessFree to download

Abstract

Objective and rationale

Latest developments

Essential decision points

Introduction

Cerebral aneurysms

Natural history of unruptured intracranial aneurysm

Rupture risk evidence (ISUIA and UCAS)

Tables and rupture risk estimates

REVIEW ARTICLE 􀀁 CONTINUUM AUDIO INTERVIEW AVAILABLE ONLINE CITE AS: CONTINUUM (MIN NEA P M INN) 2023;29(2, CEREBROVASCULAR DISEASE):584–604. Address correspondence to Dr Thanh N. Nguyen, Boston Medical Center, 85 E Concord St, Boston, MA 02118, thanh. [nguyen@bmc.org](nguyen@bmc.org). RELATIONSHIP DISCLOSURE: Dr Nguyen has received personal compensation in the range of $0 to $499 for serving on a scientific advisory or data safety monitoring board for the National Institutes of Health, and in the range of $500 to $4999 for serving on a scientific advisory or data safety monitoring board for Avania, Idorsia Pharmaceuticals, and Vesalio, and as an editor, associate editor, or editorial advisory board member for the American Heart Association. The institution of Dr Nguyen has received research support from Medtronic and the Society of Vascular and Interventional Neurology. UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Nguyen reports no disclosure. © 2023 American Academy of Neurology. Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations By Thanh Ngoc Nguyen, MD, FRCPc, FSVIN, FAHA ABSTRACT OBJECTIVE: Managing a patient with an unruptured brain aneurysm or brain arteriovenous malformation (AVM) can lead to uncertainty about preventive treatment. While the bleeding risks are low, the morbidity or mortality associated with a hemorrhagic event is not insignificant. The objective of this article is to review the natural history of these vascular entities, the risk factors for hemorrhage, preventive treatment options, and the risks of treatment. LATEST DEVELOPMENTS: Randomized trials to inform preventive treatment strategies for unruptured intracranial aneurysms and brain AVMs are ongoing. Higher angiographic obliteration rates of unruptured intracranial aneurysms have been reported with the flow-diversion technique compared with alternative standard techniques. One randomized trial for unruptured brain AVMs showed a higher rate of morbidity and mortality inpatients who underwent interventional treatment compared with observation. ESSENTIAL POINTS: The decision to treat a patient with a brain aneurysm should consider patient factors, the patient’s life expectancy, aneurysm anatomical factors, and treatment risks. Patients with unruptured brain AVMs should be observed in light of recent clinical trial data or enrolled inan ongoing clinical trial. INTRODUCTION C erebral aneurysms and arteriovenous malformations (AVMs) are commonly detected incidentally by neuroimaging. Rarely, these vascular abnormalities can rupture and lead to life-threatening consequences. Elective treatment of an unruptured intracranial aneurysm or unruptured brain AVM is not without risk, and decisions to treat should consider patient and anatomical factors, as well as the risk of repair. One “cannot make an asymptomatic person feel better.”1 A 584 APRIL 2023 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. clinician with a patient who has either a brain aneurysm or AVM is often faced with the dilemma of what to do. Thus, to provide a practical guide for the clinician, this article describes the epidemiology, natural history, pathogenesis, diagnosis, treatment, and risks of treatment of unruptured intracranial aneurysms and AVMs. CEREBRAL ANEURYSMS An aneurysm is a bulge or “balloon” that develops from a weak point of an artery, commonly at an arterial bifurcation. Aneurysms are thought to be acquired rather than congenital, with an estimated prevalence of 3% in the adult population.2 This rate is higher than previously reported and is reflective of the increased use of noninvasive imaging.3 A higher prevalence of unruptured intracranial aneurysm is seen in women, people age 30 years or older (compared with those younger than 30), those with a family history of intracranial aneurysm or prior subarachnoid hemorrhage, and

FAQs

Why is preventive treatment decision-making for unruptured aneurysms and AVMs uncertain?

Bleeding risk is relatively low, but hemorrhage can still cause significant morbidity and mortality. Elective interventions also carry inherent treatment risks, creating a risk-benefit dilemma.

What factors should be considered when deciding whether to treat an unruptured brain aneurysm?

The decision should account for patient factors, life expectancy, aneurysm anatomical characteristics, and the specific risks of treatment.

What do recent trial findings suggest about preventive strategies for brain AVMs?

Recent randomized trial data indicate higher morbidity and mortality in patients who underwent interventional treatment compared with observation, and current guidance favors observation or trial enrollment based on those results.

Aug 27, 2026

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