title: Treatment and outcomes of ARUBA-eligible patients with unruptured brain arteriovenous malformations at a single institution.
abstract: OBJECTIVE
  Management of unruptured arteriovenous malformations (AVMs) is controversial. In the first randomized trial of unruptured AVMs (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [ARUBA]), medically managed patients had a significantly lower risk of death or stroke and had better outcomes. The University of California, San Francisco (UCSF) was one of the participating ARUBA sites. While 473 patients were screened for eligibility, only 4 patients were enrolled in ARUBA. The purpose of this study is to report the treatment and outcomes of all ARUBA-eligible patients at UCSF.
  
  
  METHODS
  The authors compared the treatment and outcomes of ARUBA-eligible patients using prospectively collected data from the UCSF brain AVM registry. Similar to ARUBA, they compared the rate of stroke or death in observed and treated patients and used the modified Rankin Scale to grade outcomes.
  
  
  RESULTS
  Of 74 patients, 61 received an intervention and 13 were observed. Most treated patients had resection with or without preoperative embolization (43 [70.5%] of 61 patients). One of the 13 observed patients died after AVM hemorrhage. Nine of the 61 treated patients had a stroke or died. There was no significant difference in the rate of stroke or death (HR 1.34, 95% CI 0.12-14.53, p = 0.81) or clinical impairment (Fisher's exact test, p > 0.99) between observed and treated patients.
  
  
  CONCLUSIONS
  The risk of stroke or death and degree of clinical impairment among treated patients was lower than reported in ARUBA. The authors found no significant difference in outcomes between observed and treated ARUBA-eligible patients at UCSF. Results in ARUBA-eligible patients managed outside that trial led to an entirely different conclusion about AVM intervention, due to the primary role of surgery, judicious surgical selection with established outcome predictors, and technical expertise developed at high-volume AVM centers.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco.
authors.forename: W Caleb
authors.initials: WC
authors.lastname: Rutledge
authors.forename: Adib A
authors.initials: AA
authors.lastname: Abla
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Nelson
authors.forename: Van V
authors.initials: VV
authors.lastname: Halbach
authors.forename: Helen
authors.initials: H
authors.lastname: Kim
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004621:Embolization, Therapeutic; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D016634:Radiosurgery; D012189:Retrospective Studies; D015898:Tomography Scanners, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: ARUBA; ARUBA = A Randomized Trial of Unruptured Brain Arteriovenous Malformations; AVM = arteriovenous malformation; UCSF = University of California, San Francisco; arteriovenous malformation; mRS = modified Rankin Scale; microsurgical resection; observation