No more neurosurgery for unruptured brain AVMs?

In this blog for people with brain arterio-venous malformations (AVMs) and their relatives, Jason Yuen, Neurosurgical Registrar in South West England, looks at the latest Cochrane Review on “Interventions for treating brain arteriovenous malformations in adults” [1] and explores the implications of the review and its limitations.

Page last checked 21 April 2023

Take-home points

  • AVMs can be a serious diagnosis as haemorrhages may lead to a devastating outcome.
  • The main treatments currently include conservative management, neurosurgery, radiosurgery and embolization.
  • The ARUBA trial, which suggested conservative management was better, is the only randomised controlled trial available looking into the best treatment but there is potential bias in its data, and hence its conclusions.

AVM: is it serious?

Drake White [2], a 35-year-old country singer from Alabama, was performing in a concert in Virginia on 16th August when he suddenly felt unwell and nearly collapsed [3]. He was rushed to the emergency room, and later announced that he had previously already been diagnosed with an arterio-venous malformation (AVM) earlier in the year, which may have been the cause of his symptoms.

Compared to Drake, Neiron Ball, a young American football player was less fortunate. Despite receiving treatment for his AVM and making a significant recovery in 2011, Neiron Ball suffered from a catastrophic second bleed in December last year and died this month at the age of 27 [4]. So, an AVM can be a serious diagnosis.

Despite being a rare condition (estimated to be 18 per 100,000 adults) AVMs are one of the major causes of brain haemorrhage (bleed) in young adults [5]. They are abnormal tangles of blood vessels (probably mostly present from birth) that can not only lead to a stroke or death, but also seizures and transient neurological symptoms, such as weakness and numbness. Once a haemorrhage occurs, the risk of a second bleed is also increased. To increase its danger, AVMs are sometimes associated with aneurysms, blisters on blood vessels in the brain, which are also prone to rupture and causing haemorrhages.

How can AVMs be treated?

As imaging options such as MRI become increasing available, AVMs are being diagnosed more frequently. With that, doctors are looking into the efficacy of a number of treatments in order to prevent devastating haemorrhages from happening. The current mainstay of treatment for AVMs [6], [7] includes:

  • conservative management (“wait and see” with or without monitoring with scans),
  • medical management (such as drugs to prevent seizures),
  • neurosurgery (to remove the AVMs),
  • radiosurgery (high dose radiotherapy),
  • endovascular embolization (to occlude the AVMs by blocking the artery supplying the AVM using access through an artery, called angiogram),
  • or a combination of the above options.

All treatments carry a different degree of risks. The decision of what to offer depends on where the AVM is, its blood supply and size, and the patient’s general health [8, 9].

As doctors, it is important for us to know what the most appropriate treatment options are so we can minimise the risks to our patients, while maximising the treatment outcome.

What is the most effective and safest treatment option?

The recent Cochrane Review attempts to answer this question by reviewing the evidence available in the academic literature. It has a very strict criteria and only considers studies that are randomised controlled trials (RCTs) [10] to be of high enough quality to be included. It only includes studies of those aged 16 years or above with a brain AVM that has not previously been treated.

The study only found one trial which fit into the criteria (after filtering out 2839 other records). This is the ARUBA (A Randomized trial of Unruptured Brain Arteriovenous malformations) trial published in the Lancet in 2013 [11].

In short, the study was a first study of its kind, which randomly assigned 226 adults from nine countries to either medical management or medical management with interventions (neurosurgery, radiosurgery, embolization, or a combination). The authors suggested that intervening confers a worse outcome (in terms of dependency or death) and increase the frequency of symptomatic haemorrhage but not epileptic seizures.

No more surgery for AVM? Do we wait until it bleeds?

Most neurosurgeons would agree that ARUBA was a highly controversial study and it is not short of criticisms. There are a number of factors that may potentially lead to bias. First of all, 726 patients were eligible for the study but somehow only 226 were enrolled (323 refused but it was uncertain about the other 177 patients).

Then, the average follow-up was 33 months (with large variations). AVMs are a lifelong disease and from previous studies, radiosurgery tend to clot off the AVMs by causing scarring after two to four years. Therefore, we need longer follow-up to be certain of the outcomes. Maybe the effect of the treatment would not show until 20 years later?

76 patients of those who underwent an active treatment had low grade AVMs in this study, meaning they are probably amenable to surgery with relatively low risk. The previous studies showed that the cure rate (“obliteration”) can be up to 96% for those who underwent neurosurgery and were free from further bleeding [12]. However, in the ARUBA study, there were only five patients who underwent surgery. This does not necessarily follow the decision-making rationale that all neurosurgeons practise. Furthermore, it was not a blinded trial (both assessing clinicians and patients are aware of what intervention they have) and hence the placebo effect cannot be eliminated [13].

Despite being a study that attempts to fill the void of knowledge the neurovascular community is seeking; the ARUBA study was not considered robust enough to aid clinical decisioning by many. Therefore, the conclusions of this study must be treated with caution.

Where does this leave us?

The Cochrane Review identified three ongoing RCTs that may shed more light into this area [14], [15], [16], including one study that focuses on comparing conservative management versus intervention. At the meantime, doctors would need to offer what they think is the best treatment to patients with unruptured AVM based on their expertise and resources, taking into account clinical evidence but not just the ARUBA results.

Making decisions about treatment

Would you accept surgery on your brain to prevent a possible haemorrhage in the future? Or would you leave a known problem in your brain alone, knowing that it could potentially impact your life significantly in the future?

The key questions to put to the doctors include:

  • What is the risk of causing a significant haemorrhage if the AVM is left alone?
  • What are the benefits and risks of individual treatments?
  • What symptoms will a haemorrhage cause?

Join in the conversation on Twitter with @JasonYuenNeuro @CochraneUK @CochraneStroke or leave a comment on the blog.

References (pdf)

Jason Yuen has nothing to disclose.

No more neurosurgery for unruptured brain AVMs? by Jason Yuen

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

11 Comments on this post

  1. Hello and thank you for your post. I do want to say, in my case only, if I had opted to not treat I would be dead. I have bled three separate times and experienced a stroke as well. To spare the details I actually published a book “Malformation: when bad things happen to the right kind of people” from Westbow Press. I am not medically trained but do not following the ARUBA trial they actually cancelled the study early because of many patients deaths in the control group, those who did not medically intervene. I wrote my story in the book and challenge the reader to prove the treatment team as to the risks but for me, I would be dead if I had not pressed to get the AVMs treated. Cordially, Paul McMonagle.

    Paul McMonagle / Reply
  2. I have a right parietal lobe AVM. I have in July 2023 undergone cyberknife surgery at BC Cancer in Vancouver, BC, Canada. If interested I would be happy to provide follow up info as it occurs. My 1st Dr. follow up appt. Is Oct 13th. If of interest please let me know.

    Maggie / Reply
  3. My son-in-law found out he had AVM 2urs ago and was told nothing they could do it was growing fast and a risk to operate.
    He seems to be getting worse over the past 5 days he had 3/4 seizure’s a day, been in hospital since Thursday can’t eat can’t sleep got a bleed and infection he can barely remember a conversation from 10mins before he know been told our local hospital don’t know much so has to wait till Monday for the medical team from Walton it’s now at the stage were they want to sedate him for his own safety and on emergency care , he also believes they all lying and everyone wants him gone and he is so scared of dying only been married 1yr and has children .
    The reason for this post is what support is available for partners has its really devostating his partner thank you x

    Laren / Reply
    • Hello Laren,

      I’m passing on a reply from Jason, the author of this blog.

      He says:

      “Dear Laren, I am sad to hear about what happened to your son-in-law. I understand having an AVM is very tough for both the patients and their loved ones. In terms of support, I know there are a number of charities (e.g., that may offer support although I personally have no interactions with those. The other helpful source of support may be the neurosurgical nurse practitioners at your tertiary centre. Hope this helps.

      Please note the opinion here does not reflect any institutional or professional advice.”

      With best wishes,
      Selena [Editor]

      Selena Ryan-Vig / (in reply to Laren) Reply
  4. My cousin suffered from AVM about a year ago. We were interested in the best treatments out there. It is good to know that imaging options have become more available. He is taking the conservative management approach right now and is thinking about medical management through drugs to prevent seizures. With all of the options listed, I believe he will be fine.

    Vivian Black / Reply
  5. I was diagnosed sept 2019 of my 1.5 avm..i was hesitate to undergo surgery..I just live each day normally and offer the great life chance to God..I am into oral anti convulsants medications .

    Nerisa Palcon / Reply
  6. Hi Jason. I think it’s very unfair that AVM’s have so little research. I myself have a large inoperable AVM which is unruptured.I constantly live with debilitating migraines – my right side numb, loss of speech. I’ve tried so many medications none of them work for me. I basically am stuck in the house. What difference would it make if they tried treatment on me? It would be no different to the miserable life I lead because of this AVM. So upsetting.

    Karly / Reply
  7. Hi, I am also from Bangladesh. My father (65) has been diagnosed with large AVM in right parietal lobe. He need a surgery. Could you please help me find a better option (Doctors or hospital) for surgery or treatment.

    Thanks in advance

    Shamim Ahmed / Reply
  8. Hello..I am Muhammad Mesbah Hasan from Bangladesh.I also had a large AVM in the right temporal region in my brain and there was no serious symptom.One symptom was like this->When I used to sleep my hand were not used to stay in control,those who aplept beside me,they said the fact that my hands went to their face and I continued this all time,but fact is I did not know what was happening in the time of my sleep.This was the only symptom.Later on in 2016 I faced a sudden brain stroke .Small amount(.5ml) blooding in the right temporal AVM and it was ruptured.Then I was in the middle of death and life for 1.5 moths in Dhaka CMH.They recognised the problem but they did not do AVM surgery before.Then I my father took me to Lilavati hospital,India to Doctor Atul Goel.He immediately did my surgery after two days just after reaching India.Note that we sent the CT Angiogram,CT scan, Angiogram report to Dr Atul Goel before going to India.He said I needed a surgery.Then he did the surgery successfully and Its been 3.6 years from 2016 and I am fully well .I have not faced any problem since 3 years after my surgery.I am really grateful to Allah.Dr Atul Goel had done a great job.I will be grateful to him forever.May Allah bless him.

    Md Mesbah Hasan Mahin / Reply
  9. Hi Jason. I’m one of those few who has had not only one rupture but three. My first AVM ruptured in 2000 out of the blue. It was a massive bleed. I was paralyzed, went through rehab at Spain rehab in the University of Alabama at Birmingham, and I thought was rehabilitated. I did hold a job for a number of years. Then in 2010, I had another bleed. I did remain employed until I was let go from my job in 2017. I have since lost vision in right eye and partial in left. I can no longer work, but I am doing my best to advocate for AVM awareness. It would be helpful if we could connect. My email address is below:
    psmcmonagle at

    Paul McMonagle / Reply
  10. I have a family member who is 42 years old, male and he has a large AVM that has been determined to be inoperable by Barrow Institute and Johns Hopkins due to the location and size of the AVM. It is either on or very near the post central gyrus on the left parietal lobe. To date, the AVM has not ruptured and symptoms have been partial seizures since patient was the age of 36. He also experiences some numbness down his side and some facial sensitivity.

    alita bess / Reply

Leave a Reply

Your email address will not be published. Required fields are marked *