If you’re seeking experts to provide information on arteriovenous malformations (AVM), two Cedars-Sinai neurosurgeons are available for media interviews. Dr. Keith Black is chair of the Cedars-Sinai Medical Center Department of Neurosurgery and director of the medical center’s Maxine Dunitz Neurosurgical Institute. Dr. Wouter Schievink, director of the Neurovascular Surgery Program at Cedars-Sinai, has specialized experience in treating AVMs. Information on the symptoms, causes and treatment options for AVM is available online at: http://www.cedars-sinai.edu/5390.html#AVM.

ABOUT AVMs

Arteriovenous malformations (AVM) involve an abnormal connection between one of the brain's arteries and veins. Although most AVMs are congenital, the exact cause of their formation is unknown. Approximately 0.14% of the U.S. population is affected with AVMs, and the incidence is equal in men and women.

AVMs are troublesome for many reasons. First, AVMs allow blood from the heart to bypass the brain's capillaries, which normally deliver oxygen and nutrients to the brain tissues. This may result in neurologic deficits.

The detoured blood also causes increased pressure on the fragile wall of AVM. The AVM may become swollen due to the effects of this pressure. The ballooned AVM can press down on adjacent brain tissue, inducing seizures or causing compressive damage to surrounding brain tissue.

A much more serious complication is the risk of an AVM hemorrhage (bleeding). This can be a life-threatening emergency, damaging surrounding brain tissues and in severe cases may even result in death. It has frequently been observed that small AVMs tend to bleed more frequently than larger ones. Once an AVM has bled, the re-bleed rate is 4% per year. Fortunately, hemorrhage from an AVM is rarely fatal (<10%), which is in contrast to the high mortality rate of ruptured aneurysms (>90%). However, neurologic deficits can still result from the compression and destruction of the surrounding brain tissue.

Symptoms

The presentation of AVMs varies from person to person. Unless the AVM enlarges or bleeds, it frequently causes no symptoms. AVMs may present with new onset seizures. Seizures resulting from AVMs often occur after age 20. The symptoms of AVM hemorrhage include sudden and severe headache, vomiting, vision change, abnormal weakness, decreased sensation or a change in mental status. The headache that often heralds hemorrhage from an AVM is similar to a classic migraine.

Complications and Treatments

Upon presentation, work-up includes a complete neurologic examination to detect any deficits. Additionally, CT or MRI scans of the brain are used to diagnose AVMs. Video X-rays of blood vessels using injected dye (angiography) can provide even more detailed images of abnormal vessels in the brain.

The final goal of the treatment is to remove or cut off the blood supply to the AVM. This will prevent further growth of the AVM and eliminate the risk of rupture. Current treatment options of AVM are surgery to clip off the AVM, embolization, radiosurgery or a combination of these therapies.

The location and size of the AVM, as well as the patient's overall health and desire to undergo surgery, must be considered in the ultimate decision as to which treatment is recommended. The technical challenges of surgically excising AVMs located in the critical or deep portion of the brain make it crucial that the surgeon performing the operation is highly skilled and well versed in the appropriate approach to the AVM. The neurosurgeons at the Maxine Dunitz Neurosurgical Institute have extensive experience in surgically excising AVMs.

Embolization of AVMs involves placing a long, thin flexible tube into a blood vessel in the leg. This tube is advanced through the blood vessel to reach the AVM, and a glue-like material is then injected into the abnormal vessel, cutting off the blood flow to the AVM. Occasionally, embolization is used in combination with surgery to allow for an easier and less hazardous operation.

KEITH L. BLACK - BIO

Keith L. Black, MD serves as Chair of the Department of Neurosurgery and Director of the Maxine Dunitz Neurosurgical Institute at Cedars-Sinai Medical Center. An internationally renowned neurosurgeon and scientist, Dr. Black joined Cedars-Sinai Medical Center in July 1997 and was awarded the Ruth and Lawrence Harvey Chair in Neurosciences in November of that year.

Before joining Cedars-Sinai, Dr. Black served on the University of California, Los Angeles faculty for 10 years where he was a Professor of Neurosurgery. In 1992 he was awarded the Ruth and Raymond Stotter Chair in the Department of Surgery and was Head of the UCLA Comprehensive Brain Tumor Program.

Dr. Black pioneered research on designing ways to open the blood-brain barrier, enabling chemotherapeutic drugs to be delivered directly into the tumor. His work in this field received the Jacob Javits award from the National Advisory Neurological Disorders and Stroke Council of the National Institutes of Health in June 2000. Dr. Black, along with patients undergoing the first clinical trials of the drug RMP-7, was profiled in 1996 on the PBS program, The New Explorers, in an episode called "Outsmarting the Brain."

Dr. Black's other groundbreaking research has focused on developing a vaccine to enhance the body's immune response to brain tumors, use of gene arrays to develop molecular profiles of tumors, the use of optical technology for brain mapping, and the use of focused microwave energy to noninvasively destroy brain tumors. He was featured on the cover of Time magazine in the Fall 1997 special edition "Heroes of Medicine."

In addition to his work at Cedars-Sinai, Dr. Black serves on the editorial boards of the Journal of Neuro-Oncology, Neurological Research, Perspectives in Neurological Surgery, Critical Reviews in Neurosurgery and the Journal of Radiosurgery. He is on the National Institutes of Health's Board of Scientific Counselors for Neurological Disorders and Stroke, and was appointed to the National Advisory Neurological Disorders and Stroke Council of the National Institutes of Health from 2000 to 2004. He was recently selected as a committee member of the California Institute for Regenerative Medicine Independent Citizens Oversight Committee. He is also a member of numerous professional societies, including the American Association of Neurological Surgeons, Neurosurgical Society of America, and the Academy of Neurological Surgery. He also is a Founding Member of the North American Skull Base Society.

Dr. Black has a unique ability to combine cutting-edge research and an extremely busy surgical practice. Since 1987, he has performed more than 3,000 operations for resection of brain tumors.

Dr. Black has had a keen interest in science since childhood. At age 17, he published his first scientific paper, which earned a Westinghouse Science Award. He completed an accelerated college program at the University of Michigan and earned both his undergraduate and medical degrees in six years. He completed his internship in general surgery and residency in neurological surgery at the University of Michigan Medical Center in Ann Arbor.

WOUTER I. SCHIEVINK - BIO

Wouter I. Schievink, MD Directs the Neurovascular Surgery Program at the Maxine Dunitz Neurosurgical Institute at Cedars-Sinai Medical Center. Dr. Schievink specializes in neurovascular procedures, including the surgical treatment of aneurysms and AVMs, as well as extracranial to intracranial bypass surgery and microvascular decompression. He is a world-renowned expert in familial aneurysms and strokes.

Dr. Schievink's research has focused on the genetic, etiologic and epidemiologic aspects of intracranial aneurysms and cervicocephalic arterial dissections. He also has a special interest in cerebrospinal fluid leaks and intracranial hypotension. In the laboratory, he has conducted research on extracellular matrix proteins in intracranial aneurysms and cervicocephalic arterial dissections. He has also developed models of intracranial aneurysms. Dr. Schievink has published articles in numerous publications, including the New England Journal of Medicine, Lancet, Journal of Neurosurgery, Neurosurgery and Journal of Anatomy.

Dr. Schievink was born and raised in Amsterdam. He earned his medical degree from the University of Amsterdam, and he completed his internship and residency in neurosurgery at the Mayo Clinic in Rochester, Minnesota. He also completed a neurovascular and skull base surgery fellowship at the Barrow Neurological Institute in Phoenix.

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