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AVM: When to Defuse the Ticking Time Bomb

Dr. Robert Solomon
Dr. Robert Solomon

One of the trickiest problems Neurosurgeons face in the brain is the AVM, or arteriovenous malformation. These abnormal tangles of blood vessels can be life threatening as they are prone to rupture at any time. The surgery can be tricky though, and case by case, a neurosurgeon must decide: is it better to treat the AVM, or wait and see?

Part of the challenge of managing AVMs of the brain, has been a lack of formal data to help doctors and patients weigh the risks and benefits of early treatment. But a new study, out this month, may start to change the situation.

Published this August in the Journal of Neurosurgery, the report shows that it may be better to treat small, unruptured AVMs with few risk factors before they rupture, rather than waiting and seeing. On the other hand, the surgery to treat really difficult AVMs might be more trouble than it is worth.

While the study is in no way definitive, it has Dr. Robert Solomon, Department Chair of Neurosurgery at Columbia University Medical Center/New York Presbyterian Hospital, cautiously optimistic that the paper could lead to further development of guidelines on management of these complex disorders.

“Unlike many prior studies such as the ARUBA trial, this new paper looks at different risk factors when grading AVMs,” Dr. Solomon says.

As Dr. Solomon explained in commentary about the ARUBA trial, the prior ARUBA study made a stab at resolving this problem, but was limited by the fact that it did not look at different grades, or risks of surgical removal, of AVMs. Without that crucial piece of information, it did not offer much help regarding the decision on whether to operate or not.

The researchers collected info on patients with unruptured AVMs from 1989 to 2013, and compared their outcomes based on malformation size, location, and whether or not they received early, preemptive surgery prior to AVM rupture or bleed. Researchers also looked at brain problems from the surgeries themselves, to see if the risk of the surgery was worth the benefit of getting rid of the AVM.

“Part of the challenge in treating AVMs is weighing the risk to the patient of treating it versus not treating it,” Dr. Solomon says. “A lack of evidence-based guidelines meant that to a large extent, each neurosurgeon had to rely on his or her own experience, training and judgement to decide how to proceed on each case.”

The study found that patients with smaller unruptured AVMs located away from more important brain structures did better if they received pre-emptive surgery, rather than if they did not. However, with more complicated AVMs, the risk of the surgery often outweighed the benefits.
Only the professional advice of an experienced neurosurgeon can guide the patient making this decision, and all patients with this condition should seek such proper medical evaluation as soon as possible.

Proactive patient care strategies could potentially save qualifying patients from dangerous bleeding in the brain down the line — while at the same time literally getting the problem of the AVM off of their mind.

Read the study here, and its accompanying editorial here.

To learn more about Dr. Solomon, go to his bio page here.

patient journey

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