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Journal Club

Cerebrovascular

Re-rupture in ruptured brain arteriovenous malformations: a retrospective cohort study based on a nationwide multicenter prospective registry

Journal of NeuroInterventional Surgery | 2023

Rapid review note

Journal Club is a rapid, AI-assisted appraisal layer. It highlights study design, effect estimates, and practice relevance, but it is still a briefing, not a replacement for the paper.

For education only. Not medical advice.

Paper snapshot

Rapid study overview

Open paper

DOI

10.1136/jnis-2023-020650

PMID

N/A

PICO

Population

Patients with ruptured brain arteriovenous malformations (AVMs) from a nationwide multicenter registry

Intervention

Natural history observation (no intervention) or various treatment modalities (surgical resection, embolization, radiosurgery, combined)

Comparator

Comparison of re-rupture risk between untreated and treated periods, and between different risk factor groups

Outcomes

Annual re-rupture risk, cumulative re-rupture risk, independent risk factors for re-rupture, effect of intervention on re-rupture risk

Design

Type

Retrospective cohort study using prospective registry data

Randomized

No

Multicenter

Yes

Blinded

N/A

Follow-up

Telephone interviews or record review at 3 months, annually (1, 2, 3 years), and every 5 years after admission

Primary endpoint

Annual re-rupture risk in ruptured AVMs

Secondary endpoints

  • Cumulative re-rupture risk at 1, 3, 5, and 10 years
  • Independent risk factors for re-rupture
  • Effect of intervention timing and modality on re-rupture risk

Practice impact

What this means

Hemorrhagic stroke J NeuroIntervent Surg: first published as 10.1136/jnis-2023-020650 on 30 October 2023. Downloaded from http://jnis.bmj.com/ on November 5, 2023 at Eskind Biomedical Library Serials Original research Re-­rupture in ruptured brain arteriovenous malformations: a retrospective cohort study based on a nationwide multicenter prospective registry Kexin Yuan ‍ ‍,1 Yu Chen ‍ ‍,1 Debin Yan,1 Ruinan Li,1 Zhipeng Li ‍ ‍,1 Haibin Zhang ‍ ‍,1 Ke Wang

Bottom line

Ruptured AVMs have high re-rupture risk (7.6% annual); adult age, ventricular system involvement, and any deep venous drainage identify high-risk patients; intervention significantly reduces risk, especially surgical resection.

Strength of evidence

moderate

Recommendation

consider change

Why it matters

  • Provides robust natural history data for ruptured AVMs from large multicenter cohort.
  • Identifies clinically accessible risk factors (imaging features, age) for stratification.
  • Supports intervention benefit but highlights need for individualized decision-making given observational limitations.

What would change my mind

  • A validated full-text appraisal with explicit effect estimates and page-linked citations.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

The registry size is a strength, but this remains an observational analysis in which treatment timing and modality were not randomized, so selection bias and confounding by indication remain important.

Confounding

Multivariable Cox regression used to adjust for confounders; collinearity assessed with VIF<3. p. 3 Table 2

Missing data

Follow-up depended on telephone interviews or record review over time, so some attrition and informative censoring are possible even though the registry structure improves outcome capture.

Multiplicity

Multiple comparisons across subgroups; p-values two-sided with significance at <0.05. p. 4

Notes

  • Large sample size (n=1712) from multicenter registry enhances power.
  • Validation in multiple subcohorts (external, conservative, surgical indication) strengthens findings. p. 3-4
  • Radiological features independently evaluated by two neurointerventional radiologists with senior adjudication. p. 3

Stats check

NNT

N/A

Effect sizes

  • Adult patients: HR 1.46 (95% CI 1.09-1.97). p. 4
  • Ventricular system involvement: HR 1.52 (95% CI 1.03-2.25). p. 4
  • Any deep venous drainage: HR 1.64 (95% CI 1.02-2.82). p. 4

Absolute effects

  • Annual re-rupture risk: 7.6% (201 events/2638 person-years). p. 4
  • Cumulative re-rupture risk at 10 years: 50%. p. 4
  • Intervention reduced annual rupture risk from 11.34% to 1.70% (p<0.001). p. 5

Concerns

  • High-risk group definition (2-3 factors) appears post-hoc; validation in subcohorts mitigates but does not eliminate concern. p. 4
  • Early intervention (72% within first year) may truncate observation time, potentially underestimating natural re-rupture risk. p. 4, 6
  • Multiple treatment modality comparisons with varying sample sizes; surgical resection had smallest group (n=445) with lowest event rate. p. 5

External validity

Who it applies to

Patients similar to the study population once inclusion criteria are verified.

Who it does not

Patients outside the verified eligibility criteria.

Generalizability notes

  • External validity depends on operative workflow, center expertise, and patient selection.

Evidence trace

Source trace and metadata

Citations (5)

claim_id

methods_critique.risk_of_bias

locator

p. 6

quote

the biggest limitation of this study—the inherent bias of observational study design selective bias

claim_id

methods_critique.risk_of_bias

locator

p. 4

quote

adult patients (HR 1.46, 95% CI 1.09 to 1.97; p=0.012), ventricular system involvement (HR 1.52, 95% CI 1.03 to 2.25; p=0.033), and any deep venous drainage (HR 1.64, 95% CI 1.02 to 2.82; p=0.037)

claim_id

methods_critique.risk_of_bias

locator

p. 5

quote

Intervention could effectively reduce the risk of re-rupture.

claim_id

stats_check.concerns

locator

p. 1

claim_id

practice_impact.bottom_line

locator

p. 1

Metadata

Generated at

2026-03-09T22:30:55.927Z

Version

pdf-archive-ingest-v1