Ischemic Stroke and Epilepsy in a Spetzler-Martin Grade 5 Brain Arteriovenous Malformation: A Case Report

Background Brain arteriovenous malformations (BAVMs) are typically associated with intracranial hemorrhage. Ischemic stroke secondary to high-grade BAVM is rare and its management remains challenging. We report a complex case of a Spetzler-Martin grade 5 BAVM presenting with both newly onset cerebral infarction and late-onset epilepsy. Case presentation: A 39-year-old male with a massive right-sided BAVM (known since 2000) presented with a 6-day history of left limb weakness. Diffusion-weighted imaging (DWI) confirmed multiple acute ischemic foci in the bilateral frontal and left parietal lobes. The patient also had a history of generalized tonic-clonic seizures since 2018. Given the extreme procedural risks (Spetzler-Martin Grade 5, Lawton Supplementary Grade 8, RBAS Score 3), a conservative management strategy was adopted. Treatment focused on anti-seizure medication (sodium valproate and oxcarbazepine) and microcirculation improvement, while antiplatelet therapy was avoided due to high hemorrhagic risk. At the 3-month follow-up, the patient showed significant motor recovery and achieved seizure freedom. Conclusions This case suggests that high-grade BAVMs may trigger ischemic events through mechanisms such as the "steal phenomenon" and high-flow induced thromboembolism. For extremely high-risk BAVMs, multimodal risk stratification is essential, and conservative management can be a viable and safe option for non-hemorrhagic cases.