What's the best decision to make?

Hi there,
my name is Lorenzo, I'm a biotechnology researcher, I am
27 and I'm writing from Italy. Since I was a child I have experienced the occurrence of generalized seizures, however such phenomena were rather sporadic and resembling normal faintings, so I haven't investigated the problem for long time. When I was 22 I went to see a neurologist after a new epileptic fit and she prescribed an MRI exam. So did I, discovering an arteriovenous malformation in the left frontal area of my brain. My reaction was rather careless about it, so I didn't take care of the AVM nor did I want to take an anti-epileptic medication. I just continued my normal life without any trouble.

Suddenly, a year ago, new partial seizures
frequently occurred, affecting my vision and causing a gradual flashing distortion with a typical duration of half an hour that totally kept me from working or doing anything more than once. As the problem was particularly annoying I saw another neurologist and started an anti-epileptic therapy - Oxcarbazepine, 600mg/die - which totally eliminated the flashings. Moreover he sent me to take new MR images, and these showed a large vein next to the nidus, whose diameter was almost one centimeter. When I saw that - after four year of conservative management and observation - I became concerned about my lesion and decided to do something about it. You can view my MRI by clicking here.
Fortunately my AVM has never bled, and who knows if it ever will. However the risk of a spontaneous rupture - and especially the constant thought of such risk in my mind - is not something I want to deal with all life long. So at this point I have my mind made up: I will undergo some intervention. And it's here that a new dilemma turns up: what treatment? I have a choice to make once again and specialists are not making it easy, I have been offered different solutions and many of them are inconsistent with each other. In the best case the formula is: "there's more than one option, it's up to you to make a decision".
But I am in a funny situation where I have to decide which one is my favorite risk but honestly right now I don't even have one symptom. What am I gonna do?
Basically I should pick one of three options:
1. Direct surgical excision of the AVM
2. Partial embolization to achieve a flow reduction in the main feeder and subsequent surgical excision of the nidus.
3. Nidal embolization as a cure, eventually in multiple sessions or followed by radiosurgery to achieve complete obliteration.
What do you suggest?


The angiographic exam shows an AVM whose size is about 3 cm, fed by the left middle cerebral artery through the prefrontal artery (hypertrophic) and the lateral orbitofrontal artery (secondary feeder, not hypertrophic). The drainage is carried out by several hypertrophic cortical veins destined to the superior longitudinal sinus without any involvement of the deep venous system. The nidus shows well-demarcated borders on its posterior portion only. Follows a video of the angiography.

Cerebral angiography from Lorenzo Albanello on Vimeo.

Functional MRI
This functional MRI analysis shows the language production area for Italian (yellow) and English (green) language. The test worked really well localizing Broca's area without artifacts. Also the malformation and the arcuate fasciculus are shown through tractography as a control.

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