In this article, 23 patients with ruptured brain AVMs were treated within 10 days of the onset using Onyx. Associated intranidal or flow-related aneurysms were excluded by using of Onyx or coils. There were 10 AVMs with nidus diameter less than 1 cm, 1 pial fistula, and 12 AVMs with mean nidus diameter 2.8 cm. Complete obliteration of the AVMs was achieved in 57%. Partial obliteration was noted for the rest with successful elimination the possible causes of bleeding. No procedural related complication occurred. One patient died due to uncontrolled intracranial hypertension after surgical evacuation of related frontal hematoma.

In my opinion, decision for early treatment of ruptured AVMs is challenging. This should be balanced with patient condition and team availability. In case of small nidus, attempt for cure embolization could be possible then the risk of recurrent hemorrhage is eliminated. By the way, mass effect of hematoma might obscure existence of residual nidus. Prolonged endovascular treatment procedure might delay time to surgical evacuation of hematoma in early acute phase. In case of medium to large nidus, I agree with target specific treatment. Excessive change in hemodynamics of the AVM in a poor brain condition should be avoided.