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Original Investigation |

Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

Rustam Al-Shahi Salman, PhD1; Philip M. White, FRCR2; Carl E. Counsell, MD3; Johann du Plessis, FRCR4; Janneke van Beijnum, MD5; Colin B. Josephson, MD6; Tim Wilkinson, MRCP1; Catherine J. Wedderburn, MBChB7; Zoe Chandy, MB, ChB1; E. Jerome St. George, FRCS, SN4; Robin J. Sellar, FRCR1; Charles P. Warlow, FRCP1 ; for the Scottish Audit of Intracranial Vascular Malformations Collaborators
[+] Author Affiliations
1Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland
2Institute for Ageing and Health, Newcastle University, Newcastle-upon-Tyne, England
3Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
4Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland
5Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
6Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
7University College London Institute for Global Health, London, England
JAMA. 2014;311(16):1661-1669. doi:10.1001/jama.2014.3200.
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Importance  Whether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.

Objective  To compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.

Design, Setting, and Population  Population-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999-2003 or 2006-2010 and followed up prospectively for 12 years.

Exposures  Conservative management (no intervention) vs intervention (any endovascular embolization, neurosurgical excision, or stereotactic radiosurgery alone or in combination).

Main Outcomes and Measures  Cox regression analyses, with multivariable adjustment for prognostic factors and baseline imbalances if hazards were proportional, to compare rates of the primary outcome (death or sustained morbidity of any cause by Oxford Handicap Scale [OHS] score ≥2 for ≥2 successive years [0 = no symptoms and 6 = death]) and the secondary outcome (nonfatal symptomatic stroke or death due to bAVM, associated arterial aneurysm, or intervention).

Results  Of 204 patients, 103 underwent 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 follow-up of 6.9 years (94% completeness), the rate of progression to the primary outcome was lower with conservative management during the first 4 years of follow-up (36 vs 39 events; 9.5 vs 9.8 per 100 person-years; adjusted hazard ratio, 0.59; 95% CI, 0.35-0.99), but rates were similar thereafter. The rate of the secondary outcome was lower with conservative management during 12 years of follow-up (14 vs 38 events; 1.6 vs 3.3 per 100 person-years; adjusted hazard ratio, 0.37; 95% CI, 0.19-0.72).

Conclusions and Relevance  Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.

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Figure 1.
Participant Flow

bAVM indicates brain arteriovenous malformationaTen secondary outcomes were due to bAVM and 28 were due to intervention complications.bFive patients experiencing bAVM hemorrhage during conservative management subsequently had intervention but remained in the conservative management group for analysis of the primary outcome.cAll 14 secondary outcomes were due to bAVM.

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Figure 2.
Progression to the Primary Outcome During 12 Years of Prospective Follow-up

The primary outcome was first occurrence after inception of death due to any cause or handicap (Oxford Handicap Scale score 2-5) sustained for 2 or more successive years. Error bars indicate 95% CIs of the cumulative proportions at 4 and 12 years after inception.

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Figure 3.
Progression to the Secondary Outcome During 12 Years of Prospective Follow-up

The secondary outcome was first occurrence after inception of a nonfatal intracranial hemorrhage, cerebral infarction, or persistent/progressive nonhemorrhagic focal neurological deficit or death due to a brain arteriovenous malformation or intervention complication. Error bars indicate 95% CIs of the cumulative proportions at 4 and 12 years after inception.

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