Massive cerebral swelling with multifocal bleeding rarely occurs after a technically successful removal of cerebral arteriovenous malformation (AVM). When manifested, this frightening complication is hardly manageable. The phenomenon, termed normal, perfusion pressure breakthrough by Spetzler and Wilson, is thought to be due to a rapid diversion of the blood flow from the AVM into the adjacent, chronically dilated, non-autoregulating small blood vessels. We recently experienced a case of large patieto-occipital AVM that exhibited multifocal massive bleeding immediately after an apparently successful total removal under the surgical microscope. High-dose barbiturate administration was then initiated during surgery and was maintained for 63 hours postoperatively. Controlled hyperventilation, and steroid and osmotic dehydrating therapy were also employed to control elevation of the intracranial pressure. The patient showed a good recovery and returned home without neurological deficits except for incomplete homonymous hemianopia. As already reported by others, this protocol seems effective for the management of the nightmarish, hardly controllable cerebral swelling with bleeding that may occur as a consequence of AVM removal.