Brain AV Malformations: Conservative Treatment May Be Best For Stable Lesions Interview with: Rustam Al-Shahi Salman Professor of clinical neurology and MRC senior clinical fellow, University of Edinburgh Honorary consultant neurologist, NHS Lothian upcoming JAMA Interview with:
Rustam Al-Shahi Salman
Professor of clinical neurology and MRC senior clinical fellow
University of Edinburgh
Honorary consultant neurologist, NHS Lothian What are the main findings of the study?

Prof. Al-Shahi Salman: Patients with arteriovenous malformations (abnormal connection between arteries and veins) in the brain that have not ruptured had a lower risk of stroke or death for up to 12 years if they received conservative management of the condition compared to an interventional  treatment.

Interventional treatment for brain arteriovenous malformations (bAVMs)
with procedures such as neurosurgical excision, endovascular
embolization, or stereotactic radiosurgery can be used alone or in
combination to attempt to obliterate bAVMs. Because interventions may
have complications and the untreated clinical course of unruptured
bAVMs can be benign, some patients choose conservative management (no
intervention). Guidelines have endorsed both intervention and
conservative management for unruptured brain arteriovenous malformations. Whether conservative management is superior to interventional treatment for unruptured
bAVMs is uncertain because of the lack of long-term experience,
according to background information in the article.

Rustam Al-Shahi Salman, Ph.D., of the University of Edinburgh,
Scotland, and colleagues with the Scottish Audit of Intracranial
Vascular Malformations Collaborators, studied 204 residents of
Scotland (16 years of age or older) who were first diagnosed as having
an unruptured bAVM during 1999-2003 or 2006-2010 and followed over
time. The researchers analyzed the outcomes for patients who received
conservative management (no intervention; medications for seizures) or
an intervention (any endovascular embolization, neurosurgical
excision, or stereotactic radiosurgery alone or in combination).

Of the 204 patients, 103 underwent some type of intervention. Those
who underwent intervention were younger, more likely to have presented
with seizure, and less likely to have large bAVMs than patients
managed conservatively. During a median (midpoint) follow-up of 6.9
years, the rate of progression to sustained disability or death was
lower with conservative management during the first 4 years of
follow-up, but rates were similar thereafter. The rate of nonfatal
stroke or death (due to the brain arteriovenous malformation or intervention) was lower with conservative management during 12 years of follow-up (14 vs 38 events). Were any of the findings unexpected?

Prof. Al-Shahi Salman: These findings are very similar to the results of the ARUBA trial,
recently published in The Lancet. Comparing this population-based
observational study and the ARUBA trial, treated participants were
similar in age and sex, and in the frequencies of incidental
presentation, bAVM location, superficial venous drainage
pattern, and Spetzler-Martin grades. The frequency of multimodality
intervention was similar in ARUBA and this observational study. In the
conservative management group, the event rate was similar in ARUBA and
this observational study. Finally, the association between
conservative management and stroke or death related to bAVM or its
intervention during 12 years in the observational study (adjusted
hazard ratio [HR] 0·37, 95% CI 0·19–0·72) was similar to the effect of
conservative management on stroke or death of any cause during 6 years
in the ARUBA randomised analysis (0·27, 0·14–0·54). What should clinicians and patients take away from your report?

Prof. Al-Shahi Salman: The similarity of the results of this observational study and ARUBA and the persistent difference between the outcome of conservative
management and intervention during 12-year follow-up in our study
support the superiority of conservative management to intervention for
unruptured bAVMs, which may deter some patients and physicians from
intervention. What recommendations do you have for future research as a result of this study?

Prof. Al-Shahi Salman: Long-term follow-up in both this study and the ARUBA trial is needed to establish whether the superiority of conservative management will
persist or change.


Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

Rustam Al-Shahi Salman PhD, Philip M. White FRCR, Carl E. Counsell MD, Johann du Plessis FRCR, Janneke van Beijnum MD, Colin B. Josephson MD, Tim Wilkinson MRCP, Catherine J. Wedderburn MBChB, Zoe Chandy MB, ChB, E. Jerome St. George FRCS, SN, Robin J. Sellar FRCR, Charles P. Warlow FRCP

JAMA. 2014;311(16):1661-1669. doi:10.1001/jama.2014.3200