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. 2023 Aug;15(8):735-740.
doi: 10.1136/jnis-2022-019110. Epub 2022 Jul 28.

National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence

Evan Luther #  1 , David J McCarthy #  2 , Joshua Burks  2 , Vaidya Govindarajan  2 , Victor M Lu  3 , Michael Silva  2 , Michael Lang  4 , Bradley A Gross  4 , Robert M Starke  2
Affiliations

National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence

Evan Luther et al. J Neurointerv Surg. 2023 Aug.

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.

Keywords: arteriovenous malformation; embolic; hemorrhage; malformation; vascular malformation.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1.
Figure 1.. Pre- and Post-2014 Annual AVM Intervention rates with Segmented Linear Regression.
Figure 2.
Figure 2.. Ruptured and Unruptured AVM Percent Treatment Changes Pre- and Post-2014.
Figure 3.
Figure 3.. AVM Intervention Rates Stratified by
(A) CSF diversion in ruptured AVMs, (B) aneurysms associated with unruptured AVMs, and age for (C) ruptured AVMs and (D) unruptured AVMs; * indicates statistical significance.
Figure 4.
Figure 4.. Analyses of Annual AVM Intervention Rate and Rupture Incidence from 2003 to 2017.
(A) Segmented linear regression of annual intervention rate and rupture incidence. (B) Correlation analysis of annual intervention rate, annual rupture incidence, and time
See this image and copyright information in PMC

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