Unruptured Brain Arteriovenous Malformations
Keep Calm or Dance in a Minefield
Although there is general consensus favoring interventional treatment of ruptured brain arteriovenous malformation (bAVMs) to reduce the risk of rebleeding, the management of unruptured bAVMs is less clear. Recent natural history studies indicate that the annual risk of intracerebral hemorrhage for patients with unruptured bAVMs is low (1%–2%), but the cumulative risk increases during the patient’s lifetime. However, the rate of short-term complications of intervention seems greater than initially thought. Therefore, preventive eradication of unruptured bAVMs has been a matter of extensive and sometimes visceral debates in the past decade. The essence of the debate is whether one should keep calm and await the bAVM explosion before intervention or dance in a minefield using different bomb deactivation strategies.
A Randomised Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial1 was designed to test whether preventive lesion eradication, using any interventional treatment modality alone or in combination, offers a clinical benefit compared with medical management for patients with unruptured bAVMs. The acronym ARUBA, a reminder of the calm and peaceful Caribbean island, could not be more premonitory of the final results. The trial was prematurely stopped …