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Pial arteriovenous malformations of the brain (brain AVMs) are a rare condition. Since most brain AVMs become apparent only if they are symptomatic or as incidental findings when brain imaging is performed for a different reason, determining the prevalence of unruptured brain AVMs is difficult, and estimates range from 100 to 600/100,000 [1]. Treatment complication rates for unruptured brain AVMs have been extensively reported in the literature (although mostly in retrospective series) and the risk factors for treatment complications are reasonably well-understood, with the Spetzler-Martin grading system classifying unruptured brain AVMs according to their surgical complication risk [2]. Risk factors for endovascular and radiosurgical complications are also well-studied [3–5]. When looking at an unruptured brain AVM, experienced operators can usually quite accurately assess the complexity of a surgical, radiosurgical, and or endovascular treatment and estimate the likelihood of complications and complete cure. However, the natural history of brain AVMs remains unclear [6]. This is complicated by the fact that brain AVMs are highly variable in their size and location, feeding and draining vessels. In conjunction with patient features (age, functional status, etc.), it seems difficult to predict the natural history of an unruptured brain AVM in a given patient. The principal measure of natural history is derived from a single pre-interventional cohort of 160 patients from Finland which reflected an annual risk of 3–4%. The ARUBA trial reported a spontaneous rupture rate of 2.2% per year without treatment [7], but this estimate is likely to be biased because several subtypes of brain AVMs (e.g., multifocal or vein of Galen AVMs) and lesions that were deemed “untreatable” by the local team were excluded from the trial. Our knowledge about factors that increase bleeding risk of these lesions is sparse. There is limited evidence that deep venous drainage may increase the risk of hemorrhage, but these data were derived from very small case series and with regard to other risk factors, we are relying primarily on assumptions [8, 9]. Given the lack of knowledge about the natural history, it is almost impossible to weigh the treatment risks against the risk of rupture and subsequent bleeding. ARUBA showed that for patients with unruptured brain AVMs, natural history was superior to intervention whenmeasuring stroke and death over a 3-year follow-up. [7]. The trial, however, was criticized for its slow enrolment, failure to standardize the treatment arm, lack of subgroup analysis, and overrepresentation of certain treatment modalities. We recently conducted a multinational web-based survey (ESCAPE ALICE: EndovaSCular TreAtment Preference Evaluation at the Advanced Live Interventional Course of Essen). We obtained responses of 248 physicians from 48 countries (Figs. 1 and 2). In the first part of the survey, physicians were asked to provide their demographic baseline characteristics (age, sex, * Mayank Goyal mgoyal@ucalgary.ca

neuroradiology

What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment