Introduction: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial data reports clinical outcomes by “as randomized” and “as treated” categories and does not report radiographic cure. This strategy prevents detailed analysis of patients that could potentially benefit from interventional therapy.

Methods: In this study, 61 consecutive ARUBA-eligible patients were retrospectively reviewed and compared to ARUBA publication data. A subgroup analysis for Spetzler-Martin grades I& II (Group A), grade III (Group B) and grades IV-V (Group C) was performed. Modified Rankin scale (mRS) was used to assess functional outcome.

Results: All ARUBA-eligible patients completed treatment (Fig 1). There were significantly fewer Group A patients than ARUBA interventional therapy (p = .033, Fig 2). There were significantly more patients treated with multimodality therapy (p = .000) (Fig 3). In patients with 30 month follow-up, 4/21 (19%) were mRS 2 or greater. There were no mortalities. 6.5% Group A patients had persistent deficits, compared to 20% Group B and 40% Group C (p=.039, Fig 4). Compared to Group B & C combined, Group A patients had a lower incidence of worse mRS post treatment and mRS 2 or greater at last follow-up (p=.040, p=.026, Fig 4). 100% patients treated with surgery +/- preoperative embolization obtained radiographic cure compared to 47% patients treated with radiosurgery +/- preoperative embolization (p=.000, Fig 5). 19/31 (62%) Group A patients were treated with surgery +/- embolization and 0/19 were mRS 2 or greater at last follow-up.

Conclusions: Our ARUBA-eligible patients had higher Spetzler-Martin grades and more were treated with multimodality therapy. The results of ARUBA-eligible Group A patients show that excellent outcomes can be obtained with surgical management in this subgroup of patients.

Patient Care: This research reports a single center's experience with the multimodality management of unruptured brain AVMs and identifies a subgroup of patients with excellent outcome after surgical management.

Learning Objectives: 1) Describe the importance of subgroup analysis and radiographic cure for treatment of unruptured brain AVMs. 2) Discuss the merits of interventional therapy for unruptured brain AVMs. 3) Identify the effective treatment for subgroups of unruptured brain AVMs.

References: Mohr, J. P., et al. "Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial." The Lancet (2013).