A randomized trial of unruptured brain arteriovenous malformations trial: an editorial review.

A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) is the first randomized trial that attempts to answer the clinical question: what is the best management for an unruptured brain arteriovenous malformation (AVM).1 More concisely, is the natural history or is treatment the riskier management choice? Unquestionably, the investigators engaged in a difficult task. AVMs are different in each individual and so are their treatments.2 Therefore, any randomized trial of AVM management will pose many methodological problems and provoke criticisms from the outset and may not be able to provide definitive answers to many pivotal questions. ARUBA separated unruptured AVMs into a medical treatment alone group (109 patients) and an interventional group subjected to open surgery, radiosurgery, endovascular intervention, or combinations (114 patients).1 The study followed all of these patients until primary end points, such as death or symptomatic stroke, were reached. The study was terminated prematurely at 33.3 months because the incidence of primary end points was dramatically higher in the treatment group compared with the medical management group (30.7% versus 10.1%).1 The first great concern with this study is the generalization that one treatment method is equal in complexity to the other, that is, a simple either/or choice between 2 management methods. Medical management (observation) is a homogenous management delivery system with almost zero clinical variability between practitioners. Interventional therapy, however, represents several individual technologies and methods that are heterogeneous and complex.3 Surgery, endovascular intervention, and radiosurgery are not the same in any shape or form, and when combinations of therapy are included in the analysis, …