Abstract
Optimal management of unruptured brain arteriovenous malformations (bAVMs) remains controversial. Unruptured bAVMs are believed to confer a life-long risk of hemorrhage at approximately 1-4% per year. Treatment modalities, such as neurosurgery, radiosurgery and embolization, are able to eliminate the risk of hemorrhage, but are associated with treatment risks. Thus the risk/benefit rationale of treating unruptured bAVMs is unclear.
ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformation) was a multi-center randomized controlled trial conducted to compare conservative medical management and active intervention. It was terminated early due to a statistically significant superiority of medical management over interventional treatment, but has itself raised controversy because of its design, results and conclusions. Since its publication in 2014, the implications of ARUBA have already affected neurosurgical practice.
However, due to ARUBA's limitations, the findings are not necessarily generalizable to all bAVMs. Treatment of bAVMs should be evaluated on an individual basis, accounting for the location of bAVMs, features of the angio-architecture, patient characteristics, and the individual institutions' experience with each modality of treatment.
