THIS ARTICLE DISCUSSES the presentation, natural history, and management of arteriovenous malformations (AVMs) in elderly patients, based on our experience at the Dartmouth-Hitchcock Medical Center. We also present a review of the literature. In our series of 50 patients with AVMs who were operated on by one surgeon, six patients were 65 years old or older at the time of presentation. All six patients presented with intracerebral hemorrhage, and one patient had developed a seizure disorder 2 months before hemorrhaging. In three patients, the clinical course was consistent with the occurrence of two hemorrhages within a 48-hour period. The patients' preoperative neurological status varied from intact to moribund. In two patients, the diagnosis of AVM was made intraoperatively. Preoperative angiography revealed the diagnosis in the remaining patients. All the patients underwent surgical excision of their AVMs. Despite concurrent medical illnesses, all patients tolerated the procedure well with no new, persistent neurological deficits. At follow-up, all patients showed sufficient neurological recovery to return to the community and four of the patients were neurologically intact. Based on this experience and a review of the literature, we conclude that AVMs in elderly patients are not benign lesions and that surgical excision should be considered among the management options for these patients.