Treatment of Brain Arteriovenous Malformations

Beijnum, Janneke van; Worp, H. Bart van der; Buis, Dennis R.; Salman, Rustam Al-Shahi; Kappelle, L. Jaap; Rinkel, Gabriël J.E.; Sprenkel, Jan Willem Berkelbach van der; Vandertop, W. Peter; Algra, Ale; Klijn, Catharina J.M.

doi:10.1001/jama.2011.1632

Cited by 438 publications

(272 citation statements)

References 49 publications

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“…However, ARUBA was criticized because of its low enrollment rate, small sample size, short follow-up, high rate of adverse outcomes, under-representation of surgical treatment, and lack of treatment stratification. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Its primary outcome after interventional treatment was higher than in previous cohorts treated with microsurgery or radiosurgery [23][24][25][26][27][28][29] without a clear explanation. It combined 3 different interventions into a single amorphous category and did not discriminate which modality was harmful.…”

Section: Discussionmentioning

confidence: 82%

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Wong

Slomovic

Ibrahim

et al. 2017

Stroke

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Background and Purpose-The management of unruptured brain arteriovenous malformations (ubAVMs) remains controversial despite ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation), a controlled trial that suggested superiority of conservative management over intervention. However, microsurgery occurred in only 14.9% of ARUBA intervention cases, raising concerns about the study's generalizability. Our purpose was to evaluate whether, in a larger ARUBA-eligible ubAVM population, microsurgery produces acceptable outcomes. Methods-Demographic data, AVM characteristics, and treatment outcomes were evaluated in 155 ARUBA-eligible bAVMs treated with microsurgery between 1994 and 2014. Outcomes were rates of early disabling deficits and permanent disabling deficits with modified Rankin Scale score ≥3 or any permanent neurological deficits with modified Rankin Scale score ≥1. Covariates associated with outcomes were determined by regression analysis. Results-Of

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Section: Discussionmentioning

confidence: 82%

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Wong

Slomovic

Ibrahim

et al. 2017

Stroke

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“…A sizeable proportion of patients were treated with embolization alone (26%), despite the fact that embolization typically has the lowest obliteration rates as well as an estimated morbidity of 10% and mortality rate of 1% per embolization procedure. 3,21 Furthermore, 66% of the treated patients in ARUBA had Spetzler-Martin grade I or II AVMs, for which resection can be strongly considered at experienced centers, and radiosurgery provides an excellent risk to benefit profile. [22][23][24][25] Radiosurgery is a minimally invasive modality for the treatment of AVMs, and it is especially favorable, relative to microsurgery, for small-to moderate-sized AVMs in eloquent or deep brain areas.…”

Section: February 2016mentioning

confidence: 99%

Radiosurgery for Cerebral Arteriovenous Malformations in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)-Eligible Patients

Ding

Starke²,

Kano³

et al. 2016

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119

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Background and Purpose— The benefit of intervention for patients with unruptured cerebral arteriovenous malformations (AVMs) was challenged by results demonstrating superior clinical outcomes with conservative management from A Randomized Trial of Unruptured Brain AVMs (ARUBA). The aim of this multicenter, retrospective cohort study is to analyze the outcomes of stereotactic radiosurgery for ARUBA-eligible patients. Methods— We combined AVM radiosurgery outcome data from 7 institutions participating in the International Gamma Knife Research Foundation. Patients with ≥12 months of follow-up were screened for ARUBA eligibility criteria. Favorable outcome was defined as AVM obliteration, no postradiosurgery hemorrhage, and no permanently symptomatic radiation–induced changes. Adverse neurological outcome was defined as any new or worsening neurological symptoms or death. Results— The ARUBA-eligible cohort comprised 509 patients (mean age, 40 years). The Spetzler–Martin grade was I to II in 46% and III to IV in 54%. The mean radiosurgical margin dose was 22 Gy and follow-up was 86 months. AVM obliteration was achieved in 75%. The postradiosurgery hemorrhage rate during the latency period was 0.9% per year. Symptomatic and permanent radiation–induced changes occurred in 11% and 3%, respectively. The rates of favorable outcome, adverse neurological outcome, permanent neurological morbidity, and mortality were 70%, 13%, 5%, and 4%, respectively. Conclusions— Radiosurgery may provide durable clinical benefit in some ARUBA-eligible patients. On the basis of the natural history of untreated, unruptured AVMs in the medical arm of ARUBA, we estimate that a follow-up duration of 15 to 20 years is necessary to realize a potential benefit of radiosurgical intervention for conservative management in unruptured patients with AVM.

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“…At our centre, the number of embolisations per patient ranges from one to five (median, 2). Unfortunately, complete obliteration of AVM by embolisation alone is low [13%] (8). Thus, it is usually used in a multidisciplinary treatment program.…”

Section: Discussionmentioning

confidence: 99%

Onyx in Brain Arteriovenous Malformation Embolisation

Hashim

Muda

Aziz

et al. 2016

MJMS

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Introduction: Embolisation has long been used as an adjunct to surgical resection in the treatment of brain arteriovenous malformation (bAVM). The most commonly used embolic material, n-butylcyanoacrylate glue, requires experience and skill to handle its quick and unpredictable flow and polymerisation. A new liquid embolic agent, ethylene vinyl alcohol copolymer (Onyx), is less adhesive and polymerises slowly, which provides better control for radiologists performing embolisation.Objective: To report our experience in embolisation using Onyx alone or in combination with histoacryl for bAVM embolisation in our tertiary referral centre.Methods: We retrospectively reviewed the anatomy, technical conditions, complications and clinical outcome of all bAVM patients embolised at our centre using Onyx alone or in combination with n-butylcyanoacrylate glue.Results Conclusion: The total nidal occlusion achieved herein is comparable to other similar studies. Our morbidity and mortality were higher compared to other studies which may be attributed to the small number of patients. More data is being collected which may better reflect on our experience.

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Treatment of Brain Arteriovenous Malformations

Abstract: Although case fatality after treatment has decreased over time, treatment of brain AVM remains associated with considerable risks and incomplete efficacy. Randomized controlled trials comparing different treatment modalities appear justified.

Cited by 438 publications

References 49 publications

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Radiosurgery for Cerebral Arteriovenous Malformations in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)-Eligible Patients

Onyx in Brain Arteriovenous Malformation Embolisation

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