Endovascular embolization as a stand-alone strategy for brain arteriovenous malformations in a middle-income country: A 10-year single-institution experience

Endovascular embolization has historically complemented microsurgery or stereotactic radiosurgery for brain arteriovenous malformations (bAVMs), but advances in imaging, devices, and technique have enabled its use as a stand-alone curative therapy in selected patients. Data from resource-limited settings remain limited. We report a 10-year single-center experience with stand-alone curative embolization in a middle-income country and identify factors associated with angiographic cure.

We performed a retrospective cohort study of adults with bAVMs treated with curative-intent embolization at a tertiary center in Lima, Peru (2014-2024). Treatment strategy (transarterial, transvenous, or combined) was individualized. Baseline clinical, angiographic, and procedural variables were collected. The primary outcome was complete angiographic obliteration. Secondary outcomes included intraprocedural complications, postprocedural intracranial hemorrhage (ICH), and mortality. Logistic regression analyses identified predictors of outcomes.

Among 184 patients (median age 37 years, 55 % women), 64.7 % presented with rupture. Complete obliteration was achieved in 67.4 % overall, improving from 44.4 % in 2014-81.4 % in 2024. Smaller nidus size and fewer arterial feeders were strongly associated with cure, whereas larger size and greater feeder number independently predicted treatment failure. Intraprocedural complications occurred in 8.7 %, particularly in higher Spetzler-Martin grades. Postprocedural ICH occurred in 15.8 % and was associated with increasing feeder number. Mortality was 3.5 %.

Stand-alone curative embolization is feasible and effective in carefully selected bAVMs, especially those with favorable angioarchitectural features. Prospective comparative studies are needed to define its optimal role in bAVM management.