Management of unruptured intracranial arteriovenous malformations: a decision analysis

The management of unruptured intracranial arteriovenous malformations (AVMs) is controversial. Some authorities favor elective excision of the AVM before it bleeds, whereas others advise nonintervention unless the AVM bleeds, at which time surgical excision is performed in those who survive. A Markov model was developed that stimulates a clinical trial in which cohorts of patients with unruptured AVMs were assigned to either elective excision of their AVMs or conservative treatment (unless the AVM bled). Incremental utilities for both strategies were calculated at the end of each year after the beginning of the trial and are expressed as quality and risk-adjusted life years. The process was continued until all members of the cohorts had died. The mean quality and risk-adjusted life expectancy for members of a cohort was calculated by dividing the total number of quality and risk-adjusted life years the cohort had accumulated by the size of the cohort. If the baseline values for surgical complications were used in the computation, the quality and risk-adjusted life expectancy for the surgical cohorts was at least 1 quality and risk-adjusted life year greater than for nonsurgical cohorts up to age 44. If a more favorable complication rate were used, elective surgery could benefit selected patients in their early 60s when the location and configuration of the AVM was favorable. Elective surgical resection is justified in many instances before rupture, particularly in young patients who have intracranial AVMs that have a favorable location, size, and venous drainage.