Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study

Abstract

Background In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. Methods The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. Results A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope − 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes − 8.24%, p < 0.001; − 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). ConclusionThe rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.

Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations

“…Following the ARUBA trial results, a decrease in elective AVM interventions has been reported 79 . Subsequently, a study utilizing the National Inpatient Sample reported an increase in brain AVM admissions after 2014 with ruptured status compared to a preceding era (34.4% versus 13.3%, P < .001) 80 .…”

“…61 Following the ARUBA trial results, a decrease in elective AVM interventions has been reported. 79 Subsequently, a study utilizing the National Inpatient Sample reported an increase in brain AVM admissions after 2014 with ruptured status compared to a preceding era (34.4% versus 13.3%, P < .001). 80 These findings are to be interpreted with caution because of the reliance on administrative coding in National Inpatient Sample-related studies, the lower proportion of patients with unruptured AVM being admitted to hospitals for treatment, the potential for confounders, and the unknown denominator of unruptured brain AVM in the outpatient setting.…”