The editorial comment in the AJNR of Jan 09 by Jayaraman and Cloft is worthy of careful scrutiny, I believe. Although in my personal experience with Onyx and NBCA, final cure rates of brain AVMs from embolization alone are much lower than those published in the literature, the safety record of my patient population has been good, with one major exception. A patient in her 40′s, complaining of mild headache only, no previous bleed, ruptured a large AVM in the right frontal lobe some hours after an uneventful embolization with NBCA. The impact of this catastrophe on her life has been devastating. The question becomes, How many patients do I need to help in my career to offset the overall impact of this one calamity? I think that there is a reasonable body of doubt at this time from the observations of the ARUBA trial and other sources about how much we know concerning the natural history of unruptured AVMs and the complications we induce in doing what we think is the right thing. In the index paper by Panagiotopoulos et al. a significant complication rate of 7.3% is reported, i.e. permanent neurologic deficits. The authors are to be applauded for their honesty, but these realistic numbers are sufficiently high that they raise the question of whether these cases are worth the risk.
THIS ARTICLE REFERENCES
Jayaraman M, Cloft HJ. Embolization of Brain Arteriovenous Malformations for Cure: Because We Could or Because We Should? AJNR Am J Neuroradiol 2009;30:107-08.