Updates in arteriovenous malformation management: the post-ARUBA era

What is it about?

Brain arteriovenous malformations (AVMs) are complex and heterogeneous lesions that can rupture, causing significant morbidity and mortality. While ruptured lesions are usually treated, the management of unruptured AVMs remains unclear. The Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was the first trial conducted to compare the effects of medical and interventional therapy. Although it concluded that medical therapy was superior in preventing stroke and death over a follow-up period of 33 months, the findings were met with intense criticism regarding several aspects of study design, progression, and analysis/conclusion. Namely, the increased use of stand-alone embolization relative to microsurgery in a cohort with predominantly low-grade lesions combined with a short follow-up period amplified treatment risk. Subsequently, several observational studies were conducted on ARUBA-eligible patients to investigate the safety and efficacy of microsurgery, radiosurgery, and endovascular embolization over longer follow-up periods. These reports showed that favorable safety profiles and cure rates can be achieved with appropriate patient selection and judicious use of different treatment modalities in multi-disciplinary centers. Since large prospective randomized trials on AVMs may not be feasible, it is important to make use of practice-based data beyond the flawed ARUBA study to optimize patients’ lifetime outcomes.

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