This case is noteworthy because it combines three uncommon and clinically important elements: recurrent hemorrhagic stroke caused by a rare choroid plexus arteriovenous malformation (AVM), severe initial neurological impairment, and substantial long-term recovery despite an initially guarded prognosis. The patient presented with large-volume intracerebral hemorrhage, intraventricular extension, prolonged coma, hemiparesis, dysphagia, cognitive dysfunction, and marked dependence in activities of daily living. Such features are commonly associated with poor neurological outcomes. 2 Nevertheless, functional status improved progressively from a FIM+FAM score of 123 to 178, representing a transition from severe dependence to near-complete independence.

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The rarity of recurrent hemorrhage after prior radiosurgical treatment further increases the clinical relevance of this report. AVMs are a recognized cause of hemorrhagic stroke in younger adults, while choroid plexus AVMs remain particularly uncommon lesions described mainly in isolated reports. 1,2 Gamma Knife radiosurgery is an established treatment option for surgically challenging AVMs; however, hemorrhage risk may persist until complete obliteration of the nidus is achieved. 3,4 This case therefore reinforces the importance of long-term neurological follow-up after treatment of complex AVMs. The rehabilitation trajectory is equally noteworthy.

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During the prolonged home-based phase, functional gains were modest, whereas a more pronounced improvement was observed during the subsequent intensive outpatient multidisciplinary phase. During the home-based rehabilitation phase, the FIM+FAM score improved by 18 points, whereas a further 33-point gain occurred following admission to structured multidisciplinary rehabilitation over approximately five months. This pattern is consistent with existing evidence that coordinated stroke rehabilitation, adequate therapy intensity, goal-directed practice, and interdisciplinary management improve recovery in mobility, self-care, communication, and participation. 6-8,13,14 Although spontaneous neurological recovery and younger age may have contributed, the temporal association between organized rehabilitation and accelerated functional gains is clinically persuasive.

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Published reports of AVM-related hemorrhagic stroke have predominantly focused on acute neurosurgical management, hemorrhage control, and radiological outcomes, whereas detailed longitudinal rehabilitation trajectories are reported far less frequently. Functional recovery is often described narratively, without serial standardized outcome measures or extended community follow-up. In this context, the present case adds clinically relevant evidence by documenting sequential improvement in FIM+FAM across multiple rehabilitation phases, culminating in a return to university studies and successful community reintegration. The report is further strengthened by its setting within a middle-income health system undergoing rehabilitation development, where coordinated multidisciplinary care and caregiver involvement may be especially influential.

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Another important message concerns the role of family caregivers. In many health systems where long-term rehabilitation capacity is limited, family members become the practical extension of the rehabilitation team. Caregiver training in this case supported continuation of exercises, task-oriented practice, and reinforcement of therapeutic goals between formal sessions. The existing literature suggests that caregiver-mediated rehabilitation may enhance patient outcomes when accompanied by adequate education and professional guidance. 9 This case supports that view.

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Beyond the individual patient outcome, the report also has health-system relevance. Comparative analyses using the World Health Organization Systematic Assessment of Rehabilitation Situation framework indicate that many middle-income countries continue to face structural barriers to the integration of rehabilitation, including workforce shortages, fragmented financing, and uneven geographic access. 10-12 This case illustrates what may be achievable when organized multidisciplinary rehabilitation services become available within an emerging health system.

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Several limitations should be acknowledged. As a single case report, causal relationships between specific interventions and outcome cannot be definitively established. Recovery may partly reflect natural neurological improvement, patient motivation, family support, and the favorable influence of younger age. 13 Nevertheless, detailed longitudinal functional documentation offers meaningful clinical insight into recovery after severe recurrent AVM-related hemorrhagic stroke.

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Overall, this case corroborates current evidence that timely acute management followed by structured multidisciplinary rehabilitation can substantially improve stroke outcomes. It further adds that even rare and severe recurrent AVM-related stroke in a young adult may be followed by excellent long-term recovery when specialist rehabilitation and sustained family engagement are available.