How would you approach treatment of a brainstem AVM after hemorrhage in a patient not a candidate for surgery or embolization?

The question posted is a challenging one.

First of all, one has to wait, after a bleed, for all the blood products to disappear before an angiogram to have a good idea of the nidus in terms of location within the brain stem, size, and geometry. The patient’s neurological status after a bleed in the brainstem also influences one’s decision. Single fraction SRS (if one wants to deliver sufficient dose to have some chance of occlusion of the nidus) is likely to have a higher necrosis rate than fractionated stereotactic radiotherapy (fSRT). In the literature, there have been reports of a multitude of regimens for fSRT, e.g. 20 Gy in 4, 25-35 Gy in 4, 25 Gy in 5, 35 Gy in 5, 30 Gy in 6, 42 Gy in 6, 18 Gy in 2, with reported complete nidus occlusi...

SRS