What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment

Goyal, Mayank; Ospel, Johanna M.; Kashani, Nima; Siddiqui, Adnan H.; Hanel, Ricardó A.; Almekhlafi, Mohammed; Chapot, René

doi:10.1007/s00234-020-02365-4

Cited by 6 publications

(5 citation statements)

References 19 publications

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“…For example, we still lack good randomized controlled trial data for the treatment of unruptured brain aneurysms, and this is unlikely to change within the current decade. The same is true for the ability to practice evidence-based medicine in the treatment of unruptured brain arteriovenous malformations [36]. Furthermore, as new diagnostic tools and treatment technologies are emerging at a rapid pace and sometimes find their way into clinical routine based on anecdotal evidence, our field would largely benefit from a systematic approach to adopting new technologies.…”

Section: Desirable Developments That Will Not Happen In the Near Futurementioning

confidence: 99%

Neurointervention in the 2020s: Where are We Going?

Goyal

Zwam

Moret³

et al. 2020

Clin Neuroradiol

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The 1970s and 1980s-Discovery The history of neurointervention is short as our field is still in its puberty. If one had to pinpoint a starting date, most would agree it was the early 1970s, although Luessenhop and Spence described a case of an endovascular embolization of a brain arteriovenous malformation as early as 1960 [1]. The 1970s was the time when the pioneers of the field boldly went where no one had gone before. Their brilliant minds made huge advancements in the understanding of complex vessel anatomy and neurovascular pathology, and we have to particularly recognize the tremendous input of Pierre Lasjaunias in the delicate and precise description of the vascular microanatomy of the base of the skull, and Fedor Serbinenko, who developed a technique to treat intracranial aneurysms and carotid cavernous sinus fistulas with a detachable latex balloon [2]. In the 1980s, Zeumer and Theron entered the field of endovascular stroke treatment and opened intracranial occlusions with locally administered fibrinolytics [3, 4]. Only a few conditions were treatable but the sudden knowledge gain was massive and

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Section: Desirable Developments That Will Not Happen In the Near Futurementioning

confidence: 99%

Neurointervention in the 2020s: Where are We Going?

Goyal

Zwam

Moret³

et al. 2020

Clin Neuroradiol

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“…Several challenges need to be overcome first: more (prospective) knowledge about the ‘natural history’ of SyNC should be gathered, the role of systemic inflammatory conditions in SyNC patients should be further investigated, and robust evidence for all three treatment options needs to be created. The neurointerventional community seems to agree with this approach: in a multinational web-based survey (ESCAPE ALICE: EndovaSCular TreAtment Preference Evaluation at the Advanced Live Interventional Course of Essen),42 43 we asked 248 neurointerventionalists from 48 countries how they see the future of SyNC treatment. The majority of physicians thought that essential prerequisites to successful interventional SyNC treatment are (1) a standard definition for SyNC, and (2) a standardized imaging protocol (online supplemental figure 3A,B).…”

Section: Endovascular Sync Treatment: How To Move Forward?mentioning

confidence: 99%

Symptomatic non-stenotic carotid disease: current challenges and opportunities for diagnosis and treatment

Ospel

Kappelhof

Ganesh

et al. 2023

J NeuroIntervent Surg

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Symptomatic non-stenotic carotid plaques (SyNC) are an under-researched and under-recognized source of stroke. Various imaging markers of non-stenotic carotid plaques that are associated with stroke risk have been identified, but these causal relationships need to be confirmed in additional prospective studies. Currently, there exists neither a standardized SyNC definition nor a dedicated set of imaging protocols, although researchers have started to address these shortcomings. Moreover, many neuroradiologists are still unaware of the condition, and hence do not comment on high-risk plaque features other than stenosis in their reports. Regarding SyNC treatment, scant data exist as to whether and to what extent medical, interventional and surgical treatments could influence the course of the disease; the relative lack of data on the ‘natural’ history of untreated SyNC makes treatment comparisons difficult. In our opinion, endovascular SyNC treatment represents the most promising treatment option for SyNC, since it allows for targeted elimination of the embolic source, with few systemic side effects and without the need for general anesthesia. However, currently available carotid devices are designed to treat stenotic lesions, and thus are not optimally designed for SyNC. Developing a device specifically tailored to SyNC could be an important step towards establishing endovascular SyNC treatment in clinical practice. In this review, we provide an overview of the current state of evidence with regard to epidemiological, clinical and imaging features of SyNC, propose a SyNC definition based on imaging and clinical features, and outline a possible pathway towards evidence-based SyNC therapies, with a special focus on endovascular SyNC treatment.

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“…Following the validation of clinical outcomes, EVT will inevitably advance and integrate new modalities and techniques, but improvements may be essential because the results of ARUBA and other pragmatic studies, such as TOBAS, are quite lackluster in terms of cure and complications rates (11,91). The results are extremely different when comparing TOBAS reallife outcomes to monocentric series or industrial ones, and further research will be required to fully comprehend this discrepancy.…”

Section: The Futurementioning

confidence: 99%

“…Improvements in EVT management of bAVM are essential because the results of ARUBA and other pragmatic studies, such as TOBAS, are quite lackluster in terms of cure and complications rates. [88][89][90] The results are extremely different when comparing TOBAS real-life outcomes to monocentric series or industry-led series, and further research will be required to fully comprehend this discrepancy. A recent meta-analysis published by Ghatge and Itti about EVOHbased SM I and II bAVM management reported a 76% cure rate with a 0 to 16% risk of neurological deficits.…”

Section: The Futurementioning

confidence: 99%

Endovascular Management of Brain Arteriovenous Malformations

et al. 2023

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Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVM) are a rare and threatening disease. Concerning bAVM management, only one randomized control trial -the ARUBA trial -has been published so far. The results of the ARUBA trial favor a non-interventional approach in the case of an unruptured bAVM, however implementation of these findings is challenging in daily practice.Instead, management relies on multidisciplinary discussions that lead to patient-specific strategies based on local expertise and experience in reference centers. Given the wide patterns of presentation and multiple treatment modalities recommendations are also difficult to follow. Endovascular treatment (EVT) is a widely used modality which can be used for curative treatment, or prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e. venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents (LEA) such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion, have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT.

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What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment

Cited by 6 publications

References 19 publications

Neurointervention in the 2020s: Where are We Going?

Neurointervention in the 2020s: Where are We Going?

Symptomatic non-stenotic carotid disease: current challenges and opportunities for diagnosis and treatment

Endovascular Management of Brain Arteriovenous Malformations

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