Surgery safe and effective for patients with unruptured brain arteriovenous malformation

USA: A recent study has found surgical approaches (microsurgery, embolization, radiosurgery) to be safe and effective for the treatment of selected patients with unruptured arteriovenous malformation (AVM). 

The analysis, presented at the Society of NeuroInterventional Surgery’s (SNIS) 20th Annual Meeting, is contrary to the results of a seminal study in the field. 

AVMs are tangled blood vessels with abnormal connections between arteries and veins, bypassing the capillary system, and they are most commonly found in the brain and spinal cord. Untreated, these vessels can weaken and rupture, causing brain haemorrhage, stroke, brain damage, and death. However, treating unruptured AVMs has been controversial because of the risk of complications-including stroke and death-brain arteriovenous malformation from AVM surgery.

In 2014, a long-term study evaluating patients across nine countries, “A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA),” suggested that it’s safer to avoid surgery for people with unruptured AVMs, and alternatively, the management should be focused on treating AVM symptoms (including headaches and seizures). However, new research notes that the limitations of the ARUBA study’s results make it less generalizable to determine the guideline for treating individuals with unruptured AVMs and that neuro interventionalists and neurosurgeons can surgically treat unruptured AVMs successfully for carefully selected patients.

A new collaborative study, “Treatment Outcomes for ARUBA-Eligible Brain Arteriovenous Malformations: A Comparison of Real-World Data from the NVQI-QOD AVM Registry to the ARUBA Trial,” led by a team from Cleveland Clinic, reviewed patient information from hospitals and surgical centres around the U.S. using the Neurovascular Quality Initiative Quality Outcomes Database, on which SNIS collaborates.

“We performed a retrospective analysis of prospectively collected data of ARUBA-eligible patients, who underwent intervention at 18 participating centers,” said Nina Moore, MD, senior author of the study, researcher, and neurosurgeon at the Cleveland Clinic. “Our results suggest that intervention for unruptured brain AVMs at comprehensive stroke centres across the United States is safe and effective.”

The study authors specifically analyzed records for 173 patients who are ARUBA-eligible with similar demographics and characteristics of the AVMs, finding that more patients survived and thrived after AVM surgery than in the ARUBA study. For example, only 8.7% of surgically treated patients from this study experienced death or stroke, compared to 30.7% in the ARUBA trial. In addition, only 25.4% of patients from the database experienced post-surgery physical impairment, compared to 46.2% in the ARUBA trial. The study authors also didn’t find a difference in the risk of stroke and/or death among the surgical modalities used. As a result, the study authors suggest that comprehensive stroke centres across the United States would be able to safely surgically treat unruptured AVMs.

“Seeing through this data that neuro interventionalists and neurosurgeons can safely treat unruptured brain AVMs via different surgical modalities is very encouraging,” said Anas Alrohimi, MD, PhD, primary author, and neuroendovascular surgery fellow at the Cleveland Clinic. “In this constantly evolving field, it is crucial we continue to investigate new procedures that impact the patient’s outcomes. It’s exciting to open up opportunities to manage this potentially deadly condition and improve patients’ quality of life.”