The Prognosis and Treatment of Arteriovenous Malformations of the Brain

Al‐Shahi, Rustam; Stapf, Christian

doi:10.1111/j.1474-7766.2005.00326.x

Cited by 18 publications

(14 citation statements)

References 41 publications

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“…24 -30 In North America, suitable AVMs (such as Spetzler-Martin Grades I and II) seem to be excised more often than they are embolized, 2 but endovascular treatment (with or without radiosurgery) appears to have been used more frequently in Europe. 13 This study found minimal detectable heterogeneity between patients with AVMs evaluated at 4 neuroscience centers serving an entire population, but it detected differences in patterns of interventional AVM treatment and in particular differences between the 2 largest centers in the treatments used within the same Spetzler-Martin grade. Different patterns of interventional treatment may have arisen because of variation in the local availabilities of interventions, because of the lack of robust experimental evidence to inform our choice of whose AVM to treat and how 12 or for reasons that could not be assessed by this study.…”

Section: Discussionmentioning

confidence: 98%

“…2 Nevertheless, institutional, regional, national, and international variations in practice may exist, due to referral practices, selection for particular treatment modalities, availability of technical equipment, personal preference, and policies of health insurance systems, to name just a few reasons. 13 We sought to explore whether there were any detectable influences on regional patterns of AVM interventional treatment in one of the 2 ongoing, prospective, population-based cohort studies of AVM outcome. 3,4 …”

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confidence: 99%

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Patterns of Brain Arteriovenous Malformation Treatment

Beijnum

Bhattacharya

Counsell

et al. 2008

Stroke

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Section: Discussionmentioning

confidence: 98%

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confidence: 99%

Patterns of Brain Arteriovenous Malformation Treatment

Beijnum

Bhattacharya

Counsell

et al. 2008

Stroke

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“…Both interventional eradication and conservative follow-up are recognised management strategies in patients with brain arteriovenous malformations. 16,17 As far as we are aware, ARUBA is the first randomised controlled clinical trial assessing the outcomes from these two management strategies (ie, medical management with interventional therapy or medical management alone) in patients diagnosed with an unruptured brain arteriovenous malformation (panel). 18 …”

Section: Discussionmentioning

confidence: 99%

Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial

et al. 2014

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Summary Background The clinical benefit of preventive eradication of unruptured brain arteriovenous malformations remains uncertain. A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA) aims to compare the risk of death and symptomatic stroke in patients with an unruptured brain arteriovenous malformation who are allocated to either medical management alone or medical management with interventional therapy. Methods Adult patients (≥18 years) with an unruptured brain arteriovenous malformation were enrolled into this trial at 39 clinical sites in nine countries. Patients were randomised (by web-based system, in a 1:1 ratio, with random permuted block design [block size 2, 4, or 6], stratified by clinical site) to medical management with interventional therapy (ie, neurosurgery, embolisation, or stereotactic radiotherapy, alone or in combination) or medical management alone (ie, pharmacological therapy for neurological symptoms as needed). Patients, clinicians, and investigators are aware of treatment assignment. The primary outcome is time to the composite endpoint of death or symptomatic stroke; the primary analysis is by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00389181. Findings Randomisation was started on April 4, 2007, and was stopped on April 15, 2013, when a data and safety monitoring board appointed by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health recommended halting randomisation because of superiority of the medical management group (log-rank Z statistic of 4·10, exceeding the prespecified stopping boundary value of 2·87). At this point, outcome data were available for 223 patients (mean follow-up 33·3 months [SD 19·7]), 114 assigned to interventional therapy and 109 to medical management. The primary endpoint had been reached by 11 (10·1%) patients in the medical management group compared with 35 (30·7%) in the interventional therapy group. The risk of death or stroke was significantly lower in the medical management group than in the interventional therapy group (hazard ratio 0·27, 95% CI 0·14–0·54). No harms were identified, other than a higher number of strokes (45 vs 12, p<0·0001) and neurological deficits unrelated to stroke (14 vs 1, p=0·0008) in patients allocated to interventional therapy compared with medical management. Interpretation The ARUBA trial showed that medical management alone is superior to medical management with interventional therapy for the prevention of death or stroke in patients with unruptured brain arteriovenous malformations followed up for 33 months. The trial is continuing its observational phase to establish whether the disparities will persist over an additional 5 years of follow-up. Funding National Institutes of Health, National Institute of Neurological Disorders and Stroke.

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“…5 Because interventions may have complications 6 and the untreated clinical course of unruptured bAVMs can be benign, [1][2][3][4] some patients choose conservative management (without intervention). Unruptured bAVM intervention has been compared with conservative management in a concurrent control group in just 1 randomized trial (ARUBA) 7-9 and only a few observational studies, all of which have shown harm from intervention in the short term.…”

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confidence: 99%