Early versus Delayed Treatment of Ruptured Cerebral Arteriovenous Malformations: Equivalent Neurological Outcomes and Decreased Health Care Cost

Introduction: Earlier studies have failed to demonstrate that improved outcomes are associated with delaying surgical treatment for ruptured AVMs. Our aim was to analyze the clinical outcomes and hospital costs associated with early and delayed treatment of ruptured cerebral AVMs.

Methods: The authors retrospectively analyzed patients who underwent surgical treatment for a ruptured cerebral AVM between January 1, 2015, and December 31, 2020. Patients who underwent emergent treatment due to acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgery relative to AVM rupture into early (postbleed days 1–20) and delayed (postbleed days 21–180) treatment cohorts. A multivariate linear regression model with cost and total length of stay was utilized.

Results: The early and delayed treatment cohorts consisted of 75 patients and 12 patients, respectively. The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation (p≥0.15). Last follow-up mRS and rates of clinical improvement, stabilization, and worsening based on mRS were not significantly different between the cohorts (p = 0.65, p = 0.99, respectively). The associated mean (SD) health care costs were significantly higher in the delayed treatment cohort ($241,597 [$99,363]) than in the early treatment cohort ($133,989 [$110,947]) (p=0.02). After adjustment for length of stay, each day of delayed treatment increased cost by $2,465 (95%CI [$967 – $3,964], p = 0.002) and treatment within 20 days reduced cost by $82,416 (95%CI [$-169,748 – $4,916], p = 0.064).

Conclusion : Early and delayed resection strategies for patients with ruptured cerebral AVMs resulted in equivalent surgical and neurological outcomes. Early treatment was associated with significantly lower health care costs than delayed treatment. Given comparable patient outcomes and decreased costs, we advocate for the early treatment of ruptured cerebral AVMs when clinically indicated.