Management of unruptured brain arteriovenous malformations: surgical treatment is associated with excellent outcomes and cure

Abstract

A brain arteriovenous malformation (bAVM) is a type of congenital vascular malformation originally graded by Spetzler and Martin based on the size of the lesion, location in eloquent parenchyma, and venous drainage pattern. The management of these lesions include observation, embolization, radiosurgery, and open surgical resection. Combinations of these treatments may be pursued in select cases. Recently, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was conducted. Researchers concluded that death and disability were significantly lower in the medical management arm of the study and that medical management is superior to medical plus interventional treatment in the primary outcomes of stroke and death. However, the shortcomings of this study are many, and its conclusions are flawed and open to misinterpretation. This article will review these shortcomings and examine bAVM data and management practices in the post-ARUBA period. As we will describe, the surgical management of select bAVMs has been extensively published upon in the post-ARUBA period. Therefore, we will examine the management and outcomes of unruptured bAVMs managed with preoperative embolization followed by surgical resection. Aggressive treatment of unruptured bAVMs remains important in preventing morbidity from bleeding and may be accomplished safely in high-volume experienced neurosurgical centers.