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Original research
National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence
  1. Evan Luther1,
  2. David J McCarthy1,
  3. Joshua Burks1,
  4. Vaidya Govindarajan1,
  5. Victor M Lu2,
  6. Michael Silva1,
  7. Michael Lang3,
  8. Bradley A Gross3,
  9. Robert M Starke1
  1. 1Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
  2. 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Evan Luther, Department of Neurological Surgery, University of Miami School of Medicine, miami, Florida, USA; evan.luther{at}jhsmiami.org

Abstract

Background Recently, there has been a shift in management of unruptured cerebral arteriovenous malformations (AVMs) following studies suggesting that medical management alone was superior to interventional therapy.

Objective To evaluate the influence of contemporary AVM management on AVM rupture patterns in the United States.

Methods 154 297 AVM admissions were identified between 2003 and 2017 in the National Inpatient Sample. Annual AVM intervention and rupture rates were computed and multivariable logistic regression assessed the likelihood of AVM intervention pre- and post-2014. Segmented regression identified significant change points and fitted segmented linear models for annual intervention and rupture rates. Correlation coefficients assessed the relationship between annual AVM intervention and rupture rates.

Results For unruptured AVMs, intervention likelihood and proportion decreased after 2014 (28.1% to 22.3%, p<0.0001; adjusted OR=0.857, 95% CI 0.751 to 0.977, p=0.02). Ruptured AVM admissions increased from 14.7% to 18.6% after 2014 (p<0.0001). Between 2003 and 2017, segmented linear regression identified one significant change point in intervention rate between 2014 and 2015. Average annual percent change for rupture incidence and intervention rate increased by 0.49% (p=0.0001) and decreased by 1.17% (p=0.0001), respectively. Annual AVM intervention rates were inversely correlated with annual AVM rupture incidence (Pearson coefficient=−0.82, p=0.0002). In 2017, the annual AVM rupture rate (20.6%) surpassed the annual AVM intervention rate (19.7%).

Conclusions After 2014, the likelihood of intervention for unruptured AVMs decreased while the incidence of ruptured AVMs increased. These findings suggest that fewer unruptured AVM treatments may lead to increases in AVM rupture incidence.

  • arteriovenous malformation
  • embolic
  • hemorrhage
  • malformation
  • vascular malformation

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Twitter @evanluthermd, @UMneurosurgery

  • EL and DJM contributed equally.

  • Contributors EL: conception of the work, acquisition, analysis or interpretation of data, drafting the work, guarantor. DJM: conception of the work, acquisition, analysis or interpretation of data, drafting the work, final approval. JB: drafting the work, interpretation of data, final approval. VG: drafting the work, interpretation of data, final approval. VML: drafting the work, interpretation of data, final approval. MS: drafting the work, interpretation of data, final approval. ML: drafting the work, interpretation of data, final approval. BAG: drafting the work, interpretation of data, final approval. RMS: conception of the work, interpretation of data, drafting the work, final approval.

  • Funding RMS's research is supported by the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, and by National Institute of Health (R01NS111119-01A1) and (UL1TR002736, KL2TR002737) through the Miami Clinical and Translational Science Institute, from the National Center for Advancing Translational Sciences and the National Institute on Minority Health and Health Disparities.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.