1
|
Luther E, McCarthy DJ, Burks J, Govindarajan V, Lu VM, Silva M, Lang M, Gross BA, Starke RM. National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence. J Neurointerv Surg 2023; 15:735-740. [PMID: 35902235 PMCID: PMC10306162 DOI: 10.1136/jnis-2022-019110] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recently, there has been a shift in management of unruptured cerebral arteriovenous malformations (AVMs) following studies suggesting that medical management alone was superior to interventional therapy. OBJECTIVE To evaluate the influence of contemporary AVM management on AVM rupture patterns in the United States. METHODS 154 297 AVM admissions were identified between 2003 and 2017 in the National Inpatient Sample. Annual AVM intervention and rupture rates were computed and multivariable logistic regression assessed the likelihood of AVM intervention pre- and post-2014. Segmented regression identified significant change points and fitted segmented linear models for annual intervention and rupture rates. Correlation coefficients assessed the relationship between annual AVM intervention and rupture rates. RESULTS For unruptured AVMs, intervention likelihood and proportion decreased after 2014 (28.1% to 22.3%, p<0.0001; adjusted OR=0.857, 95% CI 0.751 to 0.977, p=0.02). Ruptured AVM admissions increased from 14.7% to 18.6% after 2014 (p<0.0001). Between 2003 and 2017, segmented linear regression identified one significant change point in intervention rate between 2014 and 2015. Average annual percent change for rupture incidence and intervention rate increased by 0.49% (p=0.0001) and decreased by 1.17% (p=0.0001), respectively. Annual AVM intervention rates were inversely correlated with annual AVM rupture incidence (Pearson coefficient=-0.82, p=0.0002). In 2017, the annual AVM rupture rate (20.6%) surpassed the annual AVM intervention rate (19.7%). CONCLUSIONS After 2014, the likelihood of intervention for unruptured AVMs decreased while the incidence of ruptured AVMs increased. These findings suggest that fewer unruptured AVM treatments may lead to increases in AVM rupture incidence.
Collapse
Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Joshua Burks
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Vaidya Govindarajan
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Silva
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| |
Collapse
|
2
|
Vetiska S, Wälchli T, Radovanovic I, Berhouma M. Molecular and genetic mechanisms in brain arteriovenous malformations: new insights and future perspectives. Neurosurg Rev 2022; 45:3573-3593. [PMID: 36219361 DOI: 10.1007/s10143-022-01883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/30/2022] [Accepted: 10/05/2022] [Indexed: 10/17/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are rare vascular lesions made of shunts between cerebral arteries and veins without the interposition of a capillary bed. The majority of bAVMs are asymptomatic, but some may be revealed by seizures and potentially life-threatening brain hemorrhage. The management of unruptured bAVMs remains a matter of debate. Significant progress in the understanding of their pathogenesis has been made during the last decade, particularly using genome sequencing and biomolecular analysis. Herein, we comprehensively review the recent molecular and genetic advances in the study of bAVMs that not only allow a better understanding of the genesis and growth of bAVMs, but also open new insights in medical treatment perspectives.
Collapse
Affiliation(s)
- Sandra Vetiska
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Thomas Wälchli
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Group of CNS Angiogenesis and Neurovascular Link, Neuroscience Center Zurich, and Division of Neurosurgery, University and University Hospital Zurich, and Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland.,Division of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ivan Radovanovic
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Moncef Berhouma
- Department of Neurosurgery, University Hospital of Dijon Bourgogne, Dijon, France. .,CREATIS Lab, CNRS UMR 5220, INSERM U1294, Lyon 1, University, Lyon, France.
| |
Collapse
|
3
|
Luther E, Govindarajan V, McCarthy DJ, Burks J, Lu V, Ramsay I, Silva M, Starke RM. Brain Arteriovenous Malformations. Neurosurg Clin N Am 2022; 33:443-448. [DOI: 10.1016/j.nec.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
4
|
Goyal M, Ospel JM, Kashani N, Siddiqui AH, Hanel R, Almekhlafi M, Chapot R. What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment. Neuroradiology 2021; 62:411-416. [PMID: 31974635 DOI: 10.1007/s00234-020-02365-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA. .,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA.
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, USA
| | - Ricardo Hanel
- Baptist Neurological Institute, Baptist Health System, Jacksonville, USA
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - René Chapot
- Department of Interventional Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany
| |
Collapse
|
5
|
Kilian A, Clancy MS, Olitsky S, Gossage JR, Faughnan ME. Screening for pulmonary and brain vascular malformations is the North American standard of care for patients with hereditary hemorrhagic telangiectasia (HHT): A survey of HHT Centers of Excellence. Vasc Med 2020; 26:53-55. [PMID: 33375920 PMCID: PMC7879226 DOI: 10.1177/1358863x20974452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexandra Kilian
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - James R Gossage
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Augusta University, Augusta, GA, USA
| | - Marie E Faughnan
- Department of Medicine, Division of Respirology, Toronto HHT Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute and the Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
6
|
Feghali J, Huang J. Updates in arteriovenous malformation management: the post-ARUBA era. Stroke Vasc Neurol 2019; 5:34-39. [PMID: 32411406 PMCID: PMC7213498 DOI: 10.1136/svn-2019-000248] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/31/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are complex and heterogeneous lesions that can rupture, causing significant morbidity and mortality. While ruptured lesions are usually treated, the management of unruptured AVMs remains unclear. A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was the first trial conducted to compare the effects of medical and interventional therapy. Although it concluded that medical therapy was superior in preventing stroke and death over a follow-up period of 33 months, the findings were met with intense criticism regarding several aspects of study design, progression, and analysis/conclusion. Namely, the increased use of stand-alone embolisation relative to microsurgery in a cohort with predominantly low-grade lesions combined with a short follow-up period amplified treatment risk. Subsequently, several observational studies were conducted on ARUBA-eligible patients to investigate the safety and efficacy of microsurgery, radiosurgery, and endovascular embolisation over longer follow-up periods. These reports showed that favourable safety profiles and cure rates can be achieved with appropriate patient selection and judicious use of different treatment modalities in multidisciplinary centres. Since large prospective randomised trials on AVMs may not be feasible, it is important to make use of practice-based data beyond the flawed ARUBA study to optimise patients' lifetime outcomes.
Collapse
Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Pierot L. [Place of interventional neuroradiology in the prevention of hemorrhagic stroke]. Presse Med 2019; 48:672-683. [PMID: 31153681 DOI: 10.1016/j.lpm.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The risk of bleeding of unruptured aneurysms is increasing with aneurysm size. Small unruptured aneurysms can be treated conservatively with a regular MRI/MRA follow-up to detect a potential increase in size. If coiling is still the main endovascular technique for the treatment of unruptured aneurysms, several other techniques are now available including stent-assisted coiling, flow diversion, and flow disruption. After ARUBA study, there is no recommendation to treat unruptured brain AVMs. According to their hemorrhagic risk, dural arteriovenous fistulas with cortical venous drainage have to be treated, generally by endovascular approach through an arterial route.
Collapse
Affiliation(s)
- Laurent Pierot
- Hôpital Maison-Blanche, service de neuroradiologie, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
| |
Collapse
|
8
|
Zhang B, Feng X, Peng F, Wang L, Guo EK, Zhang Y, Liu P, Wu Z, Liu A. Seizure predictors and outcome after Onyx embolization in patients with brain arteriovenous malformations. Interv Neuroradiol 2018; 25:124-131. [PMID: 30269666 DOI: 10.1177/1591019918801290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Brain arteriovenous malformation (bAVM)-related epilepsy can significantly affect patient quality of life. We aimed to identify the factors associated with seizures occurrence and evaluate the long-term outcome following Onyx embolization in bAVM patients. METHODS Between July 2014 and July 2016, 239 consecutive patients underwent treatment for bAVMs in our institute and were respectively analyzed. Demographics, seizure status and bAVM morphologic characteristics were recorded. Modified Engel classification was used to evaluate the long-term seizure outcomes. RESULTS Of 239 bAVM patients, 68 (28.5%) initially presented with seizures. Seizure occurrence was associated with cerebral hemorrhage history, frontal-temporal location and arterial borderzone location. Of the 37 patients who presented with initial seizures and were treated with Onyx embolization, 23 (62.2%) were treated with antiepileptic drugs (AEDs) before Onyx embolization. At the last follow-up visit, 19 (51.4%) of the 37 patients reached modified Engel class I outcome. Of the 23 patients who had ever been treated with AEDs, 12 (52.2%) were still taking AEDs at the last follow-up visit. Single-factor analysis showed that arterial borderzone location was significantly correlated with higher modified Engel class outcome ( p = 0.046). CONCLUSION Patients with bAVM hemorrhage history, frontal-temporal location and arterial borderzone location were associated with seizure occurrence. Seizure-free status was not obtained in AVM patients with arterial borderzone after embolization, though it may have benefits in other ways. The seizure-free mechanism of bAVM with Onyx embolization is worth further study.
Collapse
Affiliation(s)
- Baorui Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Feng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Peng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Luyao Wang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Er Kang Guo
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxue Wu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Motebejane MS, Royston D, Kabera G, Harrichandparsad R, Kaminsky I, Choi IS. Demographic and angioarchitectural features associated with seizures presentation in patients with brain arteriovenous malformations in Durban, KwaZulu-Natal, South Africa. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
10
|
[Treatment of brain AVMS (TOBAS): A randomized controlled trial and registry]. Neurochirurgie 2016; 62:197-202. [PMID: 27236732 DOI: 10.1016/j.neuchi.2015.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/23/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The management of unruptured and ruptured brain arteriovenous malformations (AVMs) remains controversial. The Treatment of Brain AVM Study (TOBAS) was designed to assess curative treatments in the management of AVMs. The purpose of our study is to provide a care trial context to brain AVM patients. METHODS TOBAS is a pragmatic, prospective study including 2 randomized controlled trials and a registry. All AVM patients can be recruited. The preferred management modality will be predetermined prior to randomization by the team based on clinical judgment. Patients eligible for both conservative and interventional management will be randomly allocated conservative or curative treatment. Randomization will be stratified by a treatment modality (surgery, radiosurgery or embolization) and minimized according to a history of previous rupture and Spetzler-Martin grade. A second randomization will allocate eligible patients to embolization/no embolization prior to surgery or radiosurgery. The primary outcome of the study is death (any cause) or disabling stroke (mRS>2) at 10 years. All patients managed according to clinical judgment alone will be included in the registry. The study is registered under: wwwTrials.gov, ID: NCT02098252. EXPECTED RESULTS A minimum recruitment of 540 patients is required to show that treatment can reduce the primary outcome by 10 % (from 25 to 15 %); 440 patients will be needed to show a 10 % increase in angiographic occlusion for a good clinical outcome with pre-embolization. CONCLUSION The trial is designed to offer optimal and verifiable care to patients with brain AVMs in spite of the uncertainty. We are currently seeking the participation of multiple centers.
Collapse
|
11
|
Magro E, Gentric JC, Darsaut TE, Ziegler D, Msi, Bojanowski MW, Raymond J. Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials. J Neurosurg 2016; 126:486-494. [PMID: 27128584 DOI: 10.3171/2015.6.jns15619] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The ARUBA study (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [AVMs]) on unruptured brain AVMs has been the object of comments and editorials. In the present study the authors aim to systematically review critiques, discuss design issues, and propose a framework for future trials. METHODS The authors performed a systematic review of the French and English literature on the ARUBA study published between January 2006 and February 2015. The electronic search, including the Cochrane Library, MEDLINE (PubMed and Ovid), CINAHL, and EMBASE databases, was complemented by hand searching and cross-referencing. The comments were categorized as items related to the design, the conduct, and the analysis and interpretation of the trial. RESULTS Thirty-one articles or letters were identified. The pragmatic design, with heterogeneity of patients and lack of standardization of the treatment arm, were frequently stated concerns. The choice of outcome measures was repeatedly criticized. During the trial, low enrollment rates, selection bias, and premature interruption of enrollment were frequent comments. The short follow-up period, the lack of subgroup analyses, the lack of details on the results of the various treatments, and a contentious interpretation of results were noted at the analysis stage. A fundamental problem was the primary hypothesis testing conservative management. The authors believe that other trials are needed. Future trials could be pragmatic, test interventions stratified at the time of randomization, and look for long-term, hard clinical outcomes in a large number of patients. CONCLUSIONS In the authors' view, the ARUBA trial is a turning point in the history of brain AVM management; future trials should aim at integrating trial methodology and clinical care in the presence of uncertainty.
Collapse
Affiliation(s)
- Elsa Magro
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital.,Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest; and
| | - Jean-Christophe Gentric
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital.,Groupe d'étude de la Thrombose en Bretagne Occidentale, Brest, France
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | | | - Msi
- Direction de l'Enseignement et de l'Académie CHUM
- Bibliothèque; and
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, CHUM, Notre-Dame Hospital, Montreal, Quebec
| |
Collapse
|
12
|
Darsaut TE, Magro E, Gentric JC, Batista AL, Chaalala C, Roberge D, Bojanowski MW, Weill A, Roy D, Raymond J. Treatment of Brain AVMs (TOBAS): study protocol for a pragmatic randomized controlled trial. Trials 2015; 16:497. [PMID: 26530856 PMCID: PMC4632683 DOI: 10.1186/s13063-015-1019-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 10/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background The management of unruptured brain arteriovenous malformation (AVM) patients remains controversial. Furthermore, curative attempts to treat ruptured AVM patients have not been questioned so far, and there is a lack of prospective data on clinical results according to treatment modality. Endovascular treatment is often used aiming to improve the safety or efficacy of surgery or radiation therapy, but benefits have never been documented in a trial. A care trial context is needed to evaluate interventions at the same time they are practised. Methods/Trial design TOBAS is a pragmatic, prospective, multicenter, randomized, controlled trial and registry which offers a care trial context for brain AVM patients, including surgical resection, radiosurgery or endovascular embolization, alone or combined. The study includes two RCTs and a multimodality prospective registry. The objectives of the proposed study are to assess whether preventive interventions (surgery, embolization, radiation therapy, alone or combined), selected by the local treatment team and performed as locally practiced, randomly allocated and compared with conservative management, in unruptured brain AVM patients eligible for active or conservative management, can improve the proportion of patients having an independent outcome (modified Rankin Scale (mRS) < 3, as assessed by a standardized questionnaire administered by non-masked care personnel) at 10 years. All patients judged ineligible for randomized allocation are to be entered in a multimodal registry. The objective of a nested trial in patients with ruptured or unruptured AVMs to be treated by surgery or radiation therapy, is to assess whether pre-surgical or pre-radiation embolization, randomly allocated and compared with no embolization, can improve the proportion of patients with complete eradication of the AVM, as locally adjudicated, combined with a good clinical outcome (mRS < 3). The study will require up to 2000 patients in approximately 30 centers or more, followed for 10 years. TOBAS is registered at clinicaltrials.gov: NCT02098252 as of 25 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1019-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, AB, Canada.
| | - Elsa Magro
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada. .,Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France.
| | - Jean-Christophe Gentric
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada. .,Service de Radiologie, CHU Cavale Blanche, EA 3878 GETBO, Brest, France.
| | - André Lima Batista
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - David Roberge
- Department of Radio-Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| |
Collapse
|
13
|
Bojanowski MW, Magro E, Darsaut T, Raymond J. Letter to the Editor: Improving arteriovenous malformation research and care. J Neurosurg 2015; 122:1250. [DOI: 10.3171/2014.10.jns142356] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
14
|
Nerva JD, Mantovani A, Barber J, Kim LJ, Rockhill JK, Hallam DK, Ghodke BV, Sekhar LN. Treatment Outcomes of Unruptured Arteriovenous Malformations With a Subgroup Analysis of ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-Eligible Patients. Neurosurgery 2015; 76:563-70; discussion570; quiz 570. [DOI: 10.1227/neu.0000000000000663] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The design and conclusions of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial are controversial, and its structure limits analysis of patients who could potentially benefit from treatment.
OBJECTIVE:
To analyze the results of a consecutive series of patients with unruptured brain arteriovenous malformations (BAVMs), including a subgroup analysis of ARUBA-eligible patients.
METHODS:
One hundred five patients with unruptured BAVMs were treated over an 8-year period. From this series, 90 adult patients and a subgroup of 61 patients determined to be ARUBA eligible were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades I/II, III, and IV/V was performed. The modified Rankin Scale was used to assess functional outcome.
RESULTS:
Persistent deficits, modified Rankin Scale score deterioration, and impaired functional outcome occurred less frequently in ARUBA-eligible grade I/II patients compared with grade III to V patients combined (P = .04, P = .04, P = .03, respectively). Twenty-two of 39 patients (56%) unruptured grade I and II BAVMs were treated with surgery without and with preoperative embolization, and all had a modified Rankin Scale score of 0 to 1 at the last follow-up. All patients treated with surgery without and with preoperative embolization had radiographic cure at the last follow-up.
CONCLUSION:
The results of ARUBA-eligible and unruptured grade I/II patients overall show that excellent outcomes can be obtained in this subgroup of patients, especially with surgical management. Functional outcomes for ARUBA-eligible patients were similar to those of patients who were randomized to medical management in ARUBA. On the basis of these data, in appropriately selected patients, we recommend treatment for low-grade BAVMs.
Collapse
Affiliation(s)
| | | | | | - Louis J. Kim
- Department of Neurological Surgery
- Radiology, and University of Washington, Seattle, Washington
| | - Jason K. Rockhill
- Department of Neurological Surgery
- Radiation Oncology, University of Washington, Seattle, Washington
| | - Danial K. Hallam
- Department of Neurological Surgery
- Radiology, and University of Washington, Seattle, Washington
| | - Basavaraj V. Ghodke
- Department of Neurological Surgery
- Radiology, and University of Washington, Seattle, Washington
| | - Laligam N. Sekhar
- Department of Neurological Surgery
- Radiology, and University of Washington, Seattle, Washington
| |
Collapse
|