Changes in Clinical Presentation and Treatment Over Time in Patients with Unruptured Intracranial Arteriovenous Malformations

Objective: Treatment of unruptured intracranial arteriovenous malformations (AVMs) has become controversial since the ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) study was published in 2014. We sought to analyze changes in the demographics, clinical presentation, and treatment strategies in 2 patient cohorts from the same institution separated by 40 years. Methods: We retrospectively reviewed the electronic medical records for a consecutive series of patients with unruptured intracranial AVMs seen at the Mayo Clinic between 2003 and 2017 and compared them with a previously published historical cohort from the same institution seen between 1974 and 1985. Results: There were 273 patients in the contemporary cohort, of which discovery of the AVM was incidental in 123 (45.1%), a 3.5-fold increase compared with the 13.1% out of 168 patients in the historical cohort (P < 0.0001). Consequently, the percentage of patients with seizures as the presenting symptom leading to the diagnosis of AVM decreased from 57.7% in the historical cohort to 28.9% in the contemporary cohort (P < 0.0001). Interventional treatment was utilized in 220 (81.5%) contemporary patients compared with 49 (29.2%) historical patients (P < 0.0001). Conclusions: Compared to 40 years ago, more patients are presenting with incidentally discovered intracranial AVMs and are undergoing interventional treatment. Better understanding of the natural history, developments in endovascular therapy, and stereotactic radiosurgery, as well as improvements in microsurgical techniques have led to a substantial increase in patients undergoing invasive treatment.