To the Editor: Management of any condition that requires neurosurgical intervention in pregnancy is always a challenge. The authors of the article “Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature.”1 have done an excellent job on a topic for which not much information is available. Based on the details from the available literature, the authors analyze the risk of the first hemorrhage during pregnancy from brain arteriovenous malformation (bAVM). During pregnancy, the incidence of intracerebral hemorrhage is estimated at 5 in 10,000 with a mortality that ranges from 27% to 40%.2 Although the natural history of arteriovenous malformation (AVM) during pregnancy is unknown, the increased risk of bleeding is present.3 Pregnancy is well known for physiological alteration in many elements, which includes an increase in cardiac output, an increase in heart rate, alterations at the level of vascular connective tissue regulated by hormones. The management of urgent neurological pathology should be paramount to obstetric management in patients with ruptured bAVM.3 Endovascular Management offers some advantages for the control of bleeding due to the high risk involved in Open surgery.4 Multidisciplinary management is required for the management of this condition, which is not predictable and leads to high mortality. We agree with the authors’ recommendations that there is an urgent need for a multicenter retrospective cohort study for better understanding of the management of this subgroup of patients. The key recommendation identifying age group is extremely important as none of the studies are designed as per WHO definition (15 to 49 yr) and in one study even the age group start at the age of 0 yr. Another suggestion would be to clearly define how the AVMs were diagnosed. Although in the methodology the authors state they were radiologically confirmed cases (Criteria II), but all studies did not perform radiology in all cases. For example, Forster et al5 mentioned hospital records (without further specification), Gross and colleagues6 reported angiographic diagnosis, Liu et al7 had both angiography and histopathology, and in 2 other studies the authors could confirm the diagnosis at autopsy.8,9 Apparently the study included articles where the radiological features were of AVM or the diagnosis was confirmed either at histopathology or at autopsy. Prior to the ARUBA trial, a consensus guideline on AVM management prior to ARUBA was issued by American Heart Association Science Advisory and Coordinating Committee, in February 2001.10 They recommended the following: (1) If a woman anticipates pregnancy and has a known AVM, treatment should be considered before the pregnancy. (2) If the lesion is discovered during pregnancy, a decision should be made regarding the treatment risks vs the risk of hemorrhage during the remainder of the pregnancy if the lesion is left untreated.3 This also must include the potential risk to the fetus during the intervention, whether it be by embolotherapy, surgical extirpation, or radiation, and the associated diagnostic tests.4 In most cases, such risk-benefit analysis will not support elective treatment of AVMs during pregnancy. We understand that the ARUBA trial has not affected the same and these guidelines still hold true despite the trials many critics.11 As the authors have demonstrated no increased risk of rupture in pregnancy these guidelines may still be followed. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.