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Correspondence on “National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence” by Luther et al
  1. Francis J Jareczek,
  2. Varun Padmanaban,
  3. David R Hallan,
  4. D Andrew Wilkinson
  1. Neurosurgery, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
  1. Correspondence to Dr D Andrew Wilkinson, Neurosurgery, Penn State Health Milton S Hershey Medical Center, 30 Hope DriveSuite 1200, Entrance B, Hershey 17033, Pennsylvania, USA; dwilkinson{at}

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It was with great interest that we read the paper by Luther et al 1 reporting a decrease in intervention for unruptured brain arteriovenous malformations (AVMs) with a corresponding increase in the incidence of ruptured cerebral arteriovenous malformations after the publication of A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA)2 in 2014. We commend the authors for their efforts to address an important clinical question using rigorous analytic methods. However, while the authors acknowledge the general limitations of administrative database studies, there are particular methodological limitations to studying brain AVMs and ARUBA via the Nationwide Inpatient Sample that bear mentioning—namely, the non-specificity of AVM codes, and the transition from ICD-9 (international classification of diseases, ninth revision) to ICD-10 in the US immediately following the publication of ARUBA.

First, AVM diagnosis codes are particularly non-specific. In ICD-9, cerebral AVMs were included in the code 747.81, ‘anomalies of the cerebrovascular system’. As Cloft discussed previously,3 a study of patients with this code found that only 66% had a cerebral AVM,4 while the others had cavernous malformations (13%), unruptured cerebral …

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  • Contributors FJ reviewed and collected the evidence cited in this manuscript, drafted the manuscript, critically reviewed the manuscript, and revised the manuscript. VP and DH reviewed and collected the evidence cited in this manuscript and critically reviewed the manuscript. DAW conceived of the manuscript and planned the approach, reviewed and collected the evidence cited in this manuscript, critically reviewed the manuscript, revised the manuscript, provided critical feedback throughout the drafting of the manuscript, and supervised the overall preparation and submission of the manuscript. DAW is the guarantor of the manuscript and is responsible for the overall content. No other contributors were involved in the production of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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