What Is a Brain AVM?
A brain arteriovenous malformation is a rare vascular condition that presents with abnormal connections between the arteries and veins in the brain. In a healthy brain, the arteries carry oxygen rich blood and the veins carry oxygen depleted blood from the brain back to the heart. The normal circulation relies on slow, controlled flow through tiny capillaries. But with an AVM, the blood flow becomes high pressure and rushes directly from arteries into veins through an abnormal network of vessels. Since the blood flow is high pressure, the vessel walls can stretch and weaken over time and this will increase the risk of rupture and bleeding into the brain. AVMs can be different in size and location in the brain, and present without any symptoms for years. On the other hand, others may cause seizures, headaches, neurological changes, or sudden bleeding, which can lead to stroke-like symptoms or even death. Because of these risks, brain AVMs are often evaluated carefully with imaging and treated proactively depending on patient factors and prognosis.
Why Does an AVM Matter?
As previously mentioned, brain AVMs are extremely important to screen for and monitor as they do not present with symptoms and can stay hidden in the brain for years. Eventually they can lead to neurological and bleeding complications. The most extreme complication is an intracranial hemorrhage, which is essentially bleeding in the brain caused by a rupture of the weakened abnormal vessels. This event can lead to sudden symptoms such as severe headaches, weakness, difficulty speaking, loss of consciousness, or seizures. In some cases, the bleeding can even be fatal or leave permanent neurological deficits. Even without rupture, AVMs can still be just as detrimental as they tend to “steal” blood from the surrounding brain tissue. This is often known as “Vascular Steal”. When looking to treat AVMs, we look to identify the balancing risk of rupture against benefit of treatment, considering age, medical history, and other complications of each patient. For younger patients especially, the risk accumulates over time which makes proactive care even more important.
Symptoms of a Brain AVM
The symptoms of a brain AVM vary depending on its size, location, and whether it has caused bleeding. Many people experience asymptomatic AVMs which are often discovered incidentally during imaging for other unrelated issues or yearly check-ups. But when symptoms do present, they tend to be sudden and severe. One of the most common initial symptoms of an AVM is a seizure. Other common symptoms include headaches, which can range from dull and persistent to sudden and severe, especially when bleeding occurs. AVMs can also cause neurological deficits, such as weakness, numbness, difficulty speaking, vision changes, or problems with coordination, depending on the part of the brain affected. Symptoms that present after an AVM ruptures, mirror the symptoms of a hemorrhagic stroke, leading to a sudden nausea, vomiting, confusion, loss of consciousness, and an event described as the worst headache of one’s life. In other cases, the symptoms tend to build up slowly over time as the AVM causes a Vascular Steal, where blood is diverted away from healthy areas of the brain into the AVM. Evaluation of an AVM is critical by a cerebrovascular specialist in order to determine the best course of action depending on the risks of symptoms and bleeding per individual.
How Is a Brain AVM Diagnosed?
Diagnosis of a brain AVM begins with brain imaging either because a patient is experiencing symptoms or because an AVM was found incidentally during scans for other unrelated issues. The first imaging test performed is often a CT Scan or a MRI, which can both reveal abnormal blood vessels in the brain, bleeding, or signs of prior hemorrhage. MRI Scans can especially help with showing the connection and effect of small AVMs on surrounding brain tissue. Once an AVM is suspected or confirmed, the next step would be conducting a Diagnostic Cerebral Angiogram. This is necessary to confirm an accurate and detailed AVM diagnosis. In a Diagnostic Cerebral Angiogram, a thin catheter is inserted through a small artery in the wrist or through the groin and then guided to the blood vessels that supply the brain. Contrast dye is injected once identifying the blood vessels to the brain, and this allows for high resolution X-ray images of the AVMs structure, surrounding brain tissue, and flow dynamics. A 3D rotational angiogram may also be done along with the Diagnostic Cerebral Angiogram in order to better visualize complex AVMs and map out the connectivity in respect to the rest of the brain. The cerebral angiography is minimally invasive and generally safe, but there are small risks of bleeding, vessel injury, or stroke. These risks are carefully minimized through modern techniques and being performed in-hospital centers by Dr. Yim.
How Do We Assess the Risk of a Brain AVM?
One of the most important tools used for evaluating a brain AVM is The Spetzler-Martin grading system. This scale helps neurosurgeons like myself to explore the surgical risk of removing the AVM and have conversations with patients about the risks and benefits of treatment. The grading system is based on three things: Size of the AVM, Location in the Brain, Type of Venous Drainage. Depending on the individual features of an AVM, the patient case will be given a score point total that will identify the AVM on a scale of Grade 1(lowest risk) to Grade 5(highest risk). Grade I–II: Typically safe and excellent candidates for surgical resection; Grade III: Borderline; surgery may still be reasonable, especially in experienced hands; Grade IV–V: High-risk surgical candidates; often better managed with embolization, radiosurgery, or observation. Lower grade AVM is more suitable and safer to be removed surgically, but higher grade AVMs are better suitable for non surgical approaches such as embolizations or radiosurgery. The point distribution depending on the features is listed below:
- Size of the AVM
- Small (<3 cm): 1 point
- Medium (3–6 cm): 2 points
- Large (>6 cm): 3 points
- Location in the Brain (Eloquence)
- If the AVM is located in a brain region that controls essential functions like speech, movement, or vision (called “eloquent cortex”), it adds 1 point
- If in a non-eloquent area: 0 points
- Type of Venous Drainage
- Deep venous drainage (draining into veins deep within the brain): 1 point
- Only superficial venous drainage: 0 points
Modified Spetzler-Martin Grading (Lawton-Young Supplement)
When there are borderline or complex cases of AVMs, a supplementary grading system known as The Lawton-Young Supplementary Scale is used. It specifically adds patient-specific factors to narrow down the Grade Level classification of the AVM. These scale point totals are added to the original Spetzler-Martin grade to create a total score that helps guide personalized treatment decisions. The point distribution depending on the features is listed below:
- Age of the Patient
- Younger than 20 years: 1 point
- Age 20–40: 2 points
- Over 40 years: 3 points
- History of Bleeding
- AVM has bled previously: 0 points
- AVM has not bled: 1 point
- AVM Structure
- Compact AVMs (clearly defined): 0 points
- Diffuse AVMs (poorly defined): 1 point
References
- Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986 Oct;65(4):476–83.
DOI: 10.3171/jns.1986.65.4.0476 - Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010 Jan;66(4):702–713.
DOI: 10.1227/01.NEU.0000367555.06344.C8 - Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL. Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors. Neurology. 2014 Aug 26;83(9):590–7.
DOI: 10.1212/WNL.0000000000000688
How Are the Spetzler-Martin and Modified SM Scales Used in AVM Treatment Planning?
The Spetzler-Martin (SM) grading scale and the Lawton-Young Supplementary Scale are not used to diagnose an AVM but to guide treatment selection, especially when considering microsurgical resection versus non-surgical options like embolization or radiosurgery. These scales also help to better tailor treatment plans and stratify clinical research studies according to individual patients based on anatomy, age, and other characteristics.
Treatment Options
Not all AVMs need immediate treatment. The best approach depends on the AVM’s size, location, risk of bleeding, and your overall health. The common treatment options are listed below:
1. Endovascular Embolization
Endovascular embolization is a minimally invasive treatment option for brain arteriovenous malformations. It involves inserting a small catheter through the wrist or the groin to reach the abnormal blood vessels in the brain. Once the AVM is accessed by the catheter, a liquid or mechanical substance is injected to block the abnormal blood flow arteries that feed into the AVM. The goal of the endovascular embolization is to completely shut down the blood supply flow to the AVM or reduce its size. This can be further supported with surgical resection or radiation treatment. Endovascular embolization is preferred to control high risk features present such as intranidal aneurysms and increased chances of rupture.
Types of Embolic Materials
Liquid Embolic Agents
- n-Butyl Cyanoacrylate (n-BCA): A surgical glue that hardens quickly to block the vessel.
- Onyx: A non-adhesive liquid that solidifies slower so it can be a more controlled deeper injection into the AVM source.
- PHIL (Precipitating Hydrophobic Injectable Liquid): A newer embolic agent with radiopacity and slower solidification.
How the Procedure Works
The patient is brought in hospital and prepped to be placed under general anesthesia for comfort and safety of procedure. Then the tiny catheter is inserted through the wrist or groin into the feeding artery of the AVM using X-ray guidance. Once close enough to the AVM nidus, the embolic agent is carefully injected through a microcatheter extension to block off the abnormal vessels. Usually the treatment is spaced over several procedures to treat multiple arteries. Alongside the endovascular embolization, a cerebral angiogram is performed in order to confirm how successful the procedure was and the overall degree of blockage of the AVM. Following the procedure, the patients are closely monitored in the Neuro Intensive Care Unit for any changes in neurological state. Recovery is usually quick and patients are required to comply with regular follow-ups to ensure the embolization was successful and corresponding results in depreciation of the AVM are confirmed.
Risks and Considerations
The risks with this procedure include stroke or neurologic deficit from unintentional blockage of other vessels, bleeding from rupture during the embolic agent injection, or kidney injury from the contrast dye which is very rare. It is important to note that not all AVMs can be completely embolized and it is heavily dependent on the size and location and agent used.
Advantages of Embolization
The procedure is minimally invasive meaning that there would be no surgery or incisions into the skull or brain. It often results with patients having short and smooth recovery time.
Is Embolization Right for Me?
As a dual-trained endovascular and cerebrovascular neurosurgeon, I assess each AVM individually using advanced imaging, clinical factors, and grading systems. IIn most patients, embolization offers an effective way to reduce AVM related risks and prepares the patient for further treatment. In some cases, we would be able to completely eliminate the AVM with no open surgery required at all. My approach is always personalized, evidence-based, and performed with a focus on maximizing safety and long-term outcomes.
References
- Natarajan SK, Ghodke B, Britz GW, Hallam DK, Sekhar LN. Multimodality treatment of brain arteriovenous malformations with microsurgery after embolization with Onyx: single-center experience and technical nuances. Neurosurgery. 2008;62(6 Suppl 3):1213–1226.
- Abud DG, Riva R, Nakiri GS, et al. Treatment of brain AVMs by double arterial catheterization with simultaneous injection of Onyx: technical note. J Neuroradiol. 2007;34(4):248–253.
- Saatci I, Geyik S, Yavuz K, Cekirge HS. Endovascular treatment of brain AVMs with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. J Neurosurg. 2011;115(1):78–88.
- Lawton MT, Rutledge WC, Kim H, et al. Brain arteriovenous malformations. Nat Rev Dis Primers. 2015;1:15008.
2. Microsurgical Resection
Microsurgical resection is a definitive treatment for many brain arteriovenous malformations. Surgery involves carefully removing the AVM through a craniotomy, which is a surgical opening in the skull using high-powered surgical microscopes. The goal is to completely eliminate the AVM, which treats the risk of future bleeding/rupture. For specific patient cases, surgery offers the best rate of cure compared to all other treatments.
When Is Surgery Recommended?
Microsurgical resection is most often used when the AVM is identified to be a low or moderate grade on the scale. Additionally, microsurgical resection is used when the AVM has previously bled, causes seizures, has well defined borders, and especially if the patient being treated is young and bleeding risk is suggested to remain lifetime.
How the Procedure Works
The patient is operated on in hospital and placed under general anesthesia for comfort and safety. A craniotomy is performed over the area of the location of the AVM. With the surgical microscope, the neurosurgeon is able to identify AVM feeding arteries, core, and draining veins. The feeding arteries are clipped and the core of the AVM is dissected from the surrounding brain tissue. At the end, the bone flap is replaced and the incision is closed.
Recovery and Postoperative Care
Patients are going to be monitored in the Neurocritical Care Unit for 48 hours for postoperative symptoms. But barring any complications, most patients recover well within days to weeks, depending on the AVM’s resection location and complexities. The follow up catheter angiogram is usually performed within 1-3 months to confirm complete resection of AVM.
Benefits of Surgery
The direct benefits of surgery is that there would be immediate cure with the AVM removed completely and there would be no need for radiation procedures. Surgery Procedures resolve seizures in many cases.
Risks and Considerations
Surgery also includes risks of stroke or neurological deficits depending on impacts to surrounding tissue. There could also be complications of brain bleeding during or after surgery, infection, seizures, or wound complications. For the reason of these risks, surgery is only reserved as an option for AVM patients where the benefits clearly outweigh the risks.
References
- Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476–83.
DOI: 10.3171/jns.1986.65.4.0476 - Lawton MT, Kim H, McCulloch CE, et al. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4):702–713.
DOI: 10.1227/01.NEU.0000367555.06344.C8 - Morgan MK, Davidson AS, Assaad NNA, Stoodley MA. Critical review of brain AVM surgery, surgical results, and natural history in 2017. World Neurosurg. 2017;106:948–959.
DOI: 10.1016/j.wneu.2017.07.093 - Lawton MT. Seven AVMs: Tenets and Techniques for Resection. Thieme Medical Publishers; 2014.
3. Stereotactic Radiosurgery (e.g., Gamma Knife)
Stereotactic radiosurgery (SRS) is a noninvasive treatment option that utilizes radiation in a precisely targeted manner to help specific brain arteriovenous malformations (AVMs to gradually close the abnormal vessels over time. Even though it is called radiosurgery, there is no surgery or incision involved. SRS is accomplished through very focused beams of radiation from many angles with submillimeter accuracy. In our practice, we use a robotic radiosurgery platform called CyberKnife to deliver SRS. This system and treatment option allows for more flexible delivery of the beams and provides some motion tracking and adjustment in real time.
How Does It Work?
SRS works by attacking the walls of the abnormal vessels making up the AVM. This injury subsequently results in a biological reaction which leads to a tailored process of thickening, scarring, and eventually closure of the nidus of the AVM over months to years. Once the AVM is fully obliterated, it cannot bleed. While this process is not immediate, radiosurgery is usually reserved for small-to-medium sized, and non-ruptured AVMs that are deep or difficult to reach, or not amenable to surgical resection.
Why CyberKnife?
CyberKnife has multiple advantages over traditional the SRS systems:
- With CyberKnife there is no rigid frame for the patient’s head that is needed. Instead, a custom soft mask is utilized for increased comfort.
- CyberKnife will also ensure submillimeter accuracy with tracking of motion of the head in real-time throughout the treatment.
- With CyberKnife, delivery can be delivered over multiple sessions, if required depending on the location and size of the AVM,
- This treatment system is particularly beneficial for eloquent AVMs in deep-seated locations adjacent to critical areas of the brain such as the motor cortex, brainstem, and visual pathways.
Who Is a Good Candidate for CyberKnife?
Stereotactic radiosurgery is usually ideal for patients:
- When the AVMs are small to medium size, which is generally less than 3 cm.
- It is also preferred that the patient has an AVM located in deep or eloquent brain areas where surgery would be high risk.
- It is recommended if the patient had a previous AVM rupture and if the AVM is no longer amenable to be surgically removed.
Your AVM will be evaluated by imaging, size, location, and your clinical history to determine whether SRS is a safe and effective treatment.
What to Expect During Treatment
- Planning Imaging
- The patient is going to get imaging between an MRI and occasionally a CT angiogram to map the AVM in 3D.
- In some cases, we will get a stereotactic catheter angiogram to visualize the Vascular anatomy of the AVM.
- Treatment Planning
- We organize a patient-specific radiation plan involving a collaborative team of the neurosurgeon, radiation oncologist, and a medical physicist.
- Our goal is to give the patient the best chance of getting all the radiation possible to the AVM and minimizing the radiation to the normal brain tissue.
- Treatment Day
- The patient will be on the treatment table with a mask to keep the head in a still position comfortably.
- During the treatment, the Cyberknife robot will deliver hundreds of narrow beams directed at the AVM location.
- This is a completely painless procedure, and no anesthesia is required; it usually takes about 45–90 minutes.
- Post-Treatment
- The patient will go home the same day.
- There is no need for recovery time, and most patients are back at normal routines immediately.
- The patient will have periodic follow-up imaging to monitor the progress of the AVM.
How Effective Is CyberKnife?
- AVMs that are less than 3 cm usually have obliteration rates of 70-90% over 2-3 years of the treatment.
- Larger AVMs may require staged or combined therapy, such as embolization then radiosurgery.
- Once fully occluded, the chance of bleeding is essentially zero.
Risks and Side Effects
There are risks associated with radiosurgery even though it avoids open surgery:
- Before the AVM closes within the 1-3 years from radiosurgery, the bleeding risk is still present.
- Radiation-induced edema could be a risk as well. This may be associated with headaches, fatigue or sometimes temporary neurological symptoms.
- Rare radiation necrosis could be a risk, and is especially seen in larger AVMs.
The entire treatment group will closely monitor the patient with serial imaging as well as neurological assessment.
References
- Starke RM, Kano H, Ding D, et al. Stereotactic radiosurgery for brain arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort. J Neurosurg. 2017;126(1):36–44.
DOI: 10.3171/2015.12.JNS151575 - Colombo F, Cavedon C, Casentini L, et al. CyberKnife radiosurgery for arteriovenous malformations: a single-center experience. J Neurosurg. 2009;111(3):431–438.
DOI: 10.3171/2009.2.JNS081333 - Paddick I, Lippitz B. AVM radiosurgery and the role of the radiosurgery-based grading system. Prog Neurol Surg. 2013;27:119–128.
DOI: 10.1159/000341767 - Sheehan JP, Williams BJ, Yen CP. Radiosurgery for arteriovenous malformations. Neurosurg Focus. 2014;37(3):E12.
DOI: 10.3171/2014.7.FOCUS14303
What Are the Risks of Not Treating a Brain AVM?
Choosing not to treat an AVM once identified can result in unpredictable risks with the most serious concerns being spontaneous ruptures, and a resulting intracranial hemorrhage. Studies have shown that the average annual risk of a bleeding event from a previous unruptured AVM is approximately 2-4 percent per year. The risk tends to accumulate over time, carrying a lifetime risk if untreated. If an AVM has already ruptured once, the risk of rebleeding will increase significantly for the next year. The long-term effect of AVM related hemorrhage on quality of life is profound. Untreated AVMs can cause more symptoms such as seizures, progressive neurological deficits, brain dysfunction, and chronic under-perfusion. There is a psychological burden that persists for patients when living with an untreated AVM due to anxiety and uncertainty about the chances of rupture.
Key Studies Supporting These Risks
- Kim H et al., Neurology, 2014: Meta-analysis of untreated AVMs showed 2–4% annual rupture risk, with higher rates in ruptured, deep, or high-flow lesions.
DOI: 10.1212/WNL.0000000000000688 - Stapf C et al., Lancet Neurology, 2006: Found significant morbidity and mortality following AVM rupture, even in first-time presentations.
DOI: 10.1016/S1474-4422(06)70542-3 - Mohr JP et al., ARUBA Trial, Lancet, 2014: Compared conservative management vs. interventional therapy for unruptured AVMs; controversial results emphasized the need for personalized care.
DOI: 10.1016/S0140-6736(13)62302-8
What Are Intranidal and Prenidal Aneurysms and Why Do They Matter?
Some brain AVMs are associated with small, weak spots in the blood vessels in the brain called aneurysms. The aneurysms could form either inside the AVM itself or along the feeder arteries to the AVM. Intranidal aneurysms refer to the ones within the AVM and Prenidal aneurysms refer to the ones that are prior to the AVM, in the feeding artery.
Aneurysms are important to identify and be precautious about, since they significantly increase the risk of bleeding. Several cases have suggested that AVMs with associated aneurysms have higher hemorrhage rates than the AVMs without any associated aneurysms. When rupturing and bleeding occurs, the aneurysm will primarily burst compared to the AVM.
How Are These Aneurysms Detected?
The most accurate way to identify these aneurysms is by performing a diagnostic cerebral angiogram, which provides a high-resolution map of the AVM’s arteries, nidus, and veins. This imaging tool is essential for proper diagnosis and treatment planning.
How Are They Treated?
Prenidal aneurysms will be treated endovascularly, using tiny coils/glue to block off the aneurysm and reduce the bleeding risk. And Intranidal aneurysms are more complex and hence must be targeted during embolization and then removed with the AVM during surgery if that is an option. Multimodal treatment involving embolization, surgery resection, and/or radiosurgery could all be used and necessary in some cases to optimize treatment per patient case.
References
- da Costa L, Wallace MC, ter Brugge KG, et al. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke. 2009;40(1):100–105.
DOI: 10.1161/STROKEAHA.108.520759 - Redekop G, TerBrugge K, Montanera W, Willinsky R. Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage. J Neurosurg. 1998;89(4):539–546.
DOI: 10.3171/jns.1998.89.4.0539 - Lv X, Li Y, Jiang C, et al. Endovascular treatment of AVM-associated aneurysms: a review of 50 cases. AJNR Am J Neuroradiol. 2009;30(3):701–706.
DOI: 10.3174/ajnr.A1429
Understanding the ARUBA Trial and Its Controversy
What Was the ARUBA Trial?
The ARUBA trial is a Randomized Trial of Unruptured Brain Arteriovenous Malformations. This trial was a multicenter international study aimed to answer: Should unruptured brain AVMs be treated, or is it safer to observe?
Published in The Lancet in 2014, the trial included 223 adult patients with unruptured brain AVMs, and randomized those patients to receive either medical management alone or medical management plus interventional treatment which could include surgery or embolizations.
Key Findings
- After a median follow-up of 33 months, the trial reported that the medical management group had significantly fewer strokes and deaths than the intervention group.
- In the observation group, the risk of stroke or death was 10.1%, and in the intervention group it was 30.7%.
- Authors concluded that the outcome in the intervention group was significantly worse than the medical management group.
Why Was the ARUBA Trial Controversial?
While there are important issues emerging from the ARUBA trial about risks of treatment, the neurovascular community has widely criticized the trial mainly for four reasons:
1. Short Follow-Up Duration
- Most of the natural history of an AVM will not have developed with a median follow-up of just over 33 months so this is not long enough to have a complete development of an AVM.
- AVMs deteriorate, nearly invariably, later in life and the cumulative lifetime risk of rupture in young individuals is great.
- While acute complications of an intervention were examined, transitional benefit of AVM obliteration for long term was not examined.
2. Heterogeneous and Non-Standardized Treatment Group
- The category “intervention” may have involved any combination of surgery, embolization or radiosurgery with none having a standardized protocol.
- Some patients only received embolization, which is rarely curative and usually used as a complementary treatment.
- Many AVMs may have also had poor surgical candidacy or inappropriately undertreated thus introducing bias into the trial.
3. Selection Bias and Limited Enrollment
- The trial terminated prematurely at 223 patients of the predicted 800 patients as a difference in the observed outcome was noticed sooner than expected.
- Many AVM centers withdrew or only enrolled patients with low-grade AVMs limiting how the results can be generalized.
4. Underrepresentation of Surgical Expertise
- Much of the treating centers were without experienced cerebrovascular neurosurgeons.
- Follow-up retrospective studies conducted at high-volume centers found much better outcomes using surgery, especially with low-grade AVMs (Spetzler-Martin I–II). This is directly inconsistent with the ARUBA results.
Current Interpretation in Practice
In spite of the flaws of the study, ARUBA brought to attention a real issue: treating unruptured AVMs is not a risk-free endeavor and treatment should be individualized. That said, the majority of experts do not interpret ARUBA to say that you should avoid all intervention. Instead it showcased and solidified that:
- Low-grade, surgically accessible AVMs should still be strong candidates for curative resection and have low risk.
- Deep or eloquent AVMs should still be considered for staged, multimodal therapy, especially in younger patients.
- For select patients with high-grade, asymptomatic lesions, observation may be reasonable.
In conclusion, the ARUBA trial reinforced the value of experienced, multidisciplinary evaluation, which we provide in our AVM program.
References
- Mohr JP et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383(9917):614–621.
DOI: 10.1016/S0140-6736(13)62302-8 - Lawton MT, Rutledge WC, Kim H, et al. Brain AVMs and ARUBA: the US perspective. J Neurosurg. 2015;123(2): 643–648.
DOI: 10.3171/2014.10.JNS132693 - Potts MB, Zumofen DW, Raz E, et al. The ARUBA study: a planned end to a controversy? World Neurosurg. 2014;82(6):e859–e861.
DOI: 10.1016/j.wneu.2014.08.005
Why Choose Dr. Yim for AVM Treatment?
As a neurosurgeon with training and experience in both open surgery for AVMs as well as endovascular procedures, I provide a comprehensive approach to the care of AVMs. My practice provides embolization for AVMs, through to complex open surgery for resection of the AVM. Each individual patient requires a different approach based on the characteristics of the AVM, medical comorbidities, and other relevant factors. As appropriate, I work with radiation oncologists, neurointensivists, and epilepsy specialists, and have the capacity to use advanced surgical techniques while offering personalized care in the East Bay.
Interested in learning more about our practice?
