Superiority of medical management for unruptured AVMs is durable

  • Mohr JP & al.
  • Lancet Neurol
  • 1 Jul 2020

  • curated by Susan London
  • Clinical Essentials
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Takeaway

  • Among patients with unruptured brain arteriovenous malformations (AVMs), medical management carries a 69% lower risk for death or symptomatic stroke at ~4 years when compared with interventional therapy.

Why this matters

  • Uncertainty has persisted regarding the longer-term benefits and risks of the 2 treatment strategies.
  • Editorial mentions disappointment that the U.S. government declined to fund the trial’s 5-year follow-up but notes the similarity of the current findings with long-term outcomes data from an ongoing population-based observational study.

Key results

  • During a mean 50.4-month follow-up, medical management vs interventional therapy yielded lower risk for death or symptomatic stroke:
    • Incidence: 3.39 vs 12.32 per 100 patient-years.
    • HR: 0.31 (95% CI, 0.17-0.56).
  • Risk for death was nonsignificantly lower (HR, 0.49; 95% CI, 0.09-2.67).
  • Of 4 deaths in the interventional therapy group, 2 were attributed to the intervention.
  • The medical management group had a lower risk for adverse events:
    • Incidence: 58.97 vs 78.73 per 100 patient-years.
    • Risk difference: −19.76 (95% CI, −30.33 to −9.19).

Study design

  • Extended follow-up of an international randomized controlled trial among 226 adults with unruptured brain AVMs (ARUBA trial):
    • Medical management (pharmacologic therapy for neurologic symptoms as needed) alone vs
    • Medical management plus interventional therapy (neurosurgery, embolization, and/or stereotactic radiotherapy).
  • Trial stopped early, at mean 33.3-month follow-up, because of superiority of medical management alone.
  • Main outcome: death or symptomatic stroke.
  • Funding: National Institute of Neurological Disorders and Stroke; Vital Projects Fund.

Limitations

  • Limited power because of early enrollment cessation.
  • Shortened follow-up because of lack of funding.