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Dr. Solomon Shares AVM Expertise in New Video

Dr. Robert A. Solomon Video Presentation: “Surgical Resection of Cerebral Arteriovenous Malformations”

(Please be aware that some of the content in this video may be too graphic for some people as there are videos of Dr. Solomon’s work in the operating room.)

Neurosurgery Department Chair Dr. Robert Solomon is recognized around the world as an expert on a brain condition that is rare but serious. It’s a tangle of blood vessels in the brain known as an arteriovenous malformation, or AVM.

Dr. Solomon’s expertise on blood vessel disorders in the brain has been sought by neurosurgeons in the United States and internationally (including last year by the German Academy of Neurosurgery). And now that expertise is available on our website. In a new video, Dr. Solomon explains the controversy around a recent AVM study and presents what he’s learned after treating more than a thousand of these tangles.

The study is called ARUBA. (It stands for A Randomized trial of Unruptured Brain Arteriovenous malformations—which is to say, AVMs in the brain that haven’t ruptured, or begun bleeding.) The ARUBA study made waves when the authors claimed that surgery for unruptured AVMs was not a good choice.

But it turns out, Dr. Solomon says, that the authors’ conclusion is not supported very well by their study.

One problem with ARUBA, explains Dr. Solomon in the video, is that its conclusions are based on a small number of patients who were treated with surgery—only 18 out of 226 patients in the study. This is a small number of patients for an international study, since it can be hard to account for all the necessary factors with only 18 cases to draw from.

Another problem is that a hefty proportion of those 18 patients were not the best candidates for surgery to begin with. Based on the size, location and blood flow of an AVM, surgeons determine how risky surgical removal is likely to be. They assign it a grade, from Roman numeral I to V. (Note that only a neurosurgeon should determine the grade of an AVM and whether surgery is necessary):

  • Grade I: Least risky to remove – An example of a Grade I AVM would be a small AVM with a simple blood flow right at the surface of the brain. It is straightforward for a neurosurgeon to access and remove, and the benefits of surgery far outweigh the risks.
  • Grade II: Also considered low risk for surgery – Removal of a Grade II might be a little more complicated than a Grade I, but the benefits of surgery are still likely to outweigh the risks.
  • Grade III: Moderate risk – The size, location and/or blood flow of a Grade III AVM mean that surgery may or may not be a good option. For example, the AVM may be near an area of the brain crucial for thought or speech, so that removing it would carry particular risk to that area.
  • Grade IV: Risky to remove surgically – The risks of surgery are likely to be greater than the benefits.
  • Grade V: Highest risk for removal – A Grade V AVM, for example, could be large, with a complicated blood flow, deep within the brain. It may be impossible to remove without disturbing brain areas crucial to thought or memory. Surgery would not usually be recommended.

In the ARUBA study, results of low-risk Grade I and II AVM surgeries were lumped in with the moderate-risk Grade III surgeries.

The final problem with ARUBA, says Dr. Solomon, is that not all the surgeons in the study were necessarily “credentialed as experts” in disorders of blood flow in the brain. “Being an expert in AVM surgery is critical to achieving good results,” says Dr. Solomon. Surgeons like Dr. Solomon who specialize in the problem are likely to have better overall outcomes when treating it.

Then Dr. Solomon gives a summary of more than 200 of his own AVM surgeries, organized based on the grade of the AVM. The patients in the two lowest risk groups (Grade I and Grade II) did wonderfully. Essentially 100 percent of them were fully cured by surgery, and almost none suffered any neurological side effects.

In the medium risk group, Grade III, almost all patients were completely cured, but about 15 percent had neurological side effects after surgery. When it comes to surgery, the Grade III group needs the most careful consideration, says Dr. Solomon. He does not perform or recommend surgery for every patient in the Grade III group and urges fellow surgeons to be extremely selective when deciding whether to operate.

He does not consider Grade IV and V AVMs, the highest risk groups, good candidates for traditional surgery at all. Some of these AVMs can instead be treated with a process called embolization, and some are best managed by simply following them.

Throughout the video, Dr. Solomon presents lessons from his own cases. In some, both he and the patients are highly satisfied with the outcome. But in another case he presents, he would do things differently if he could handle the case again. He shares both case types so that everyone can learn from his experiences.

Dr. Solomon acknowledges that there is more to learn about treating AVMs. He finishes his presentation with a slide that summarizes what his years of experience have taught him about the surgical treatment of AVMs.

He recommends that young, healthy patients with Grade I or II AVMs be treated by expert surgeons at regional centers of excellence. Small Grade III AVMs that have not ruptured are usually best treated with radiation, but some Grade III patients may do better with surgery at regional centers of excellence. Grade IV and V AVMs should generally not be treated with surgery.

To find out more—from the expert himself!—watch the video above.

Read more about Dr. Solomon on his bio page here.

Return to Columbia Neurosurgery.

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