• Adeel Ilyas, Ching-Jen Chen, Isaac Josh Abecassis, Fadi Al-Saiegh, Natasha Ironside, Pascal M Jabbour, Stavropoula Tjoumakaris, M Reid Gooch, Cheng-Chia Lee, Jason P Sheehan, and Dale Ding.
• Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
• Neurosurgery. 2022 Nov 1; 91 (5): 684692684-692.

BackgroundThe outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs.ObjectiveTo test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies.MethodsWe performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage.ResultsThe study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration.ConclusionSRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.Copyright © Congress of Neurological Surgeons 2022. All rights reserved.

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