Management of Adult Unruptured Brain Arteriovenous Malformations: An Updated Network Meta-Analysis

Adam A. Dmytriw, Jerry Ku, Sherief Ghozy, Sahibjot Grewal, Nicole M. Cancelliere, Ahmed Y. Azzam, Robert W. Regenhardt, James D. Rabinov, Christopher J. Stapleton, Krunal Patel, Aman B. Patel, Vitor Mendes Pereira, Michael Tymianski

Research output: Contribution to journalReview articlepeer-review

Abstract

The management of unruptured brain arteriovenous malformations (ubAVMs) is a complex challenge to neurovascular practitioners. This meta-analysis aimed to identify the optimal management of ubAVMs comparing conservative management, embolization, radiosurgery, microsurgical resection, and multimodality. The search strategy was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Ovid Medline, Embase, Web of Science, and Cochrane Library databases to identify relevant papers. Using R version 4.1.1., a frequentist network meta-analysis was conducted to compare different management modalities for the ubAVMs. Overall, the conservative group had the lowest risk of rupture (P-score=0.77), and the lowest rate of complications was found in the conservative group (P-score=1). Among different interventions, the multimodality group had the highest rupture risk (P-score=0.34), the lowest overall complications (P-score=0.75), the best functional improvement (P-score=0.65), and the lowest overall mortality (P-score=0.8). However, multimodality treatment showed a significantly higher risk of rupture (odds ratio [OR]=2.13; 95% confidence interval [95% CI]=1.18–3.86) and overall complication rate (OR=5.56; 95% CI=3.37–9.15) compared to conservative management; nevertheless, there were no significant differences in overall mortality or functional independence when considered independently. Conservative management is associated with the lowest rupture risk and complication rate overall. A multimodal approach is the best option when considering mortality rates and functional improvement in the context of existing morbidity/symptoms. Microsurgery, embolization, and radiosurgery alone are similar to the natural history in terms of functional improvement and mortality, but have higher complication rates.

Original languageEnglish
Pages (from-to)80-89
Number of pages10
JournalNeurointervention
Volume18
Issue number2
DOIs
StatePublished - Jul 2023
Externally publishedYes

Keywords

  • A Randomized Trial of Unruptured Brain Arteriove-nous Malformations
  • Arteriovenous malformation
  • Neurosurgery

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