Updates in arteriovenous malformation management: the post-ARUBA era

Feghali, James; Huang, Judy

doi:10.1136/svn-2019-000248

Cited by 46 publications

(33 citation statements)

References 49 publications

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“…While intervention is recommended in ruptured AVMs with complete nidal obliteration as the therapeutic goal to strive for [ 4 ], medical management alone has been reported to be superior to a combined management including intervention in ARUBA, a multicentre, randomised controlled trial of unruptured AVMs [ 25 , 26 ]. This has led to controversial discussions about the different treatment options for unruptured AVMs, details of which can be found elsewhere [ 4 , 11 ]. Our results refer to microsurgical resection with or without preceding embolization and cannot be transferred to other therapeutic options such as stereotactic radiosurgery or embolization alone.…”

Section: Discussionmentioning

confidence: 99%

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

et al. 2021

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Background Resection of cerebral arteriovenous malformations (AVM) is technically demanding because of size, eloquent location or diffuse nidus. Controlled arterial hypotension (CAH) could facilitate haemostasis. We performed a study to characterize the duration and degree of CAH and to investigate its association with blood loss and outcome. Methods We retrospectively analysed intraoperative arterial blood pressure of 56 patients that underwent AVM-resection performed by the same neurosurgeon between 2003 and 2012. Degree of CAH, AVM size, grading and neurological outcome were studied. Patients were divided into two groups, depending on whether CAH was performed (hypotension group) or not (control group). Results The hypotension group consisted of 28 patients, which presented with riskier to treat AVMs and a higher Spetzler-Martin grading. CAH was achieved by application of urapidil, increasing anaesthetic depth or a combination thereof. Systolic and mean arterial blood pressure were lowered to 82 ± 7 and 57 ± 7 mmHg, respectively, for a median duration of 58 min [25% percentile: 26 min.; 75% percentile: 107 min]. In the hypotension group, duration of surgery (4.4 ± 1.3 h) was significantly (p < 0.001) longer, and median blood loss (500 ml) was significantly (p = 0.002) higher than in the control group (3.3 ± 0.9 h and 200 ml, respectively). No case fatalities occurred. CAH was associated with a higher amount of postoperative neurological deficits. Conclusions Whether CAH caused neurological deficits or prevented worse outcomes could be clarified by a prospective randomised study, which is regarded as ethically problematic in the context of bleeding. CAH should only be used after strict indication and should be applied as mild and short as possible.

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Section: Discussionmentioning

confidence: 99%

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

et al. 2021

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“…The risks associated with treatment and the uncertain benefit in the short term in unselected patients, especially after results of ARUBA trial [ 112 ], make patients’ management challenging. A better stratification of patients is needed to identify those with high AVM rupture risk, who would benefit from interventional treatment [ 113 ].…”

Section: Clinical Applicationsmentioning

confidence: 99%

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

et al. 2022

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Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.

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“…The treatment decision-making algorithm proposed during the COVID-19 pandemic is given in Figure 1. The suggested treatment options for brain tumours [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] are enlisted in Table 1.…”

Section: Specific Scenariosmentioning

confidence: 99%

Radiotherapeutic management of brain tumours during the COVID-19 pandemic

et al. 2020

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Aim: The coronavirus disease (COVID-19) pandemic is bound to put tremendous pressure on the existing healthcare system. This aim of this technical note is to help in triaging patients with brain tumours who are sent for radiotherapy during this pandemic and to provide safe and evidence-based care. Materials and Methods: Published data for this review were identified by systematically searching PubMed database from November 2007 onwards with the following Medical Subject Heading (Mesh) terms ‘Brain tumours’, ‘COVID-19’, ‘coronavirus’, ‘SARS-nCoV-2’, ‘Radiotherapy’, ‘Guidelines’ ‘hypofractionation’ using Boolean search algorithm. Articles in English language were reviewed. Results: We tried to apply the as low as reasonable achievable (ALARA) principle in triaging and management of patients for radiotherapy. We identified protocols which have hypofractionated regimens (reducing patient visits to hospital, time spent in treatment console) with similar outcomes when compared to conventional fractionated regimens and not overburdening the healthcare facility. We also identified the tumours for which we could safely avoid or delay the initiation of radiotherapy. Conclusion: Treatment decisions made during the COVID-19 pandemic rely on the safety first/do no harm principle and evidence-based prioritisation of cases for triage. This article is a tool to aid in triaging and prioritising brain tumour patient management. This is for consideration during the pandemic only and certainly not as a strategy for permanent practice change.

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Updates in arteriovenous malformation management: the post-ARUBA era

Cited by 46 publications

References 49 publications

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

Radiotherapeutic management of brain tumours during the COVID-19 pandemic

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