In Reply Neurosurgical colleagues have raised issues about our study comparing conservative management and intervention for unruptured bAVMs that do not invalidate our findings but instead provide an opportunity to give more detail, correct misinterpretations, and reemphasize the hierarchy of evidence.1
First, it is unlikely that some of the “other” deaths in the conservative group were related to untreated bAVMs. Every death was adjudicated with all available clinical, radiographic, and pathological information. The 26 other deaths were due to cancer (n = 9), infection (n = 6), cardiovascular disease (n = 5), ischemic stroke unrelated to bAVM (n = 4), subdural hematoma unrelated to bAVM (n = 1), and drug overdose (n = 1). Dr Zaidi and colleagues note that 4 deaths in the intervention group and 11 deaths in the conservative group were possibly due to bAVM. Given that we did not prespecify this comparison, a post hoc comparison should be interpreted cautiously; we will continue to monitor deaths.
Rustam Al-Shahi Salman, Carl E. Counsell, Philip M. White. Conservative Management vs Intervention for Unruptured Brain Arteriovenous Malformations—Reply. JAMA. 2014;312(10):1058–1059. doi:10.1001/jama.2014.8759