Management of brain arteriovenous malformations

Abstract

In response to ARUBA,1Mohr JP Parides MK Stapf C et al.Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial.Lancet. 2014; 383: 614-621Summary Full Text Full Text PDF PubMed Scopus (770) Google Scholar many clinicians concluded that observation of unruptured brain arteriovenous malformations is superior to microsurgical resection. However, ARUBA turned out to be a strikingly non-surgical trial (18 surgical patients, 19%), showing a trend away from microsurgery. 76 (81%) patients were treated with non-surgical modalities; a glaring omission was the associated cure rate. Cures with embolisation are less than 25%,2Raymond J Iancu D Weill A et al.Embolization as one modality in a combined strategy for the management of cerebral arteriovenous malformations.Interv Neuroradiol. 2005; 11: 57-62Crossref PubMed Google Scholar, 3Pierot L Cognard C Herbreteau D et al.Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO).Eur Radiol. 2013; 23: 2838-2845Crossref PubMed Scopus (96) Google Scholar and aggressive embolisation to increase this rate increases morbidity. Radiosurgery obliteration rates are less than 70%.4Starke RM Yen CP Ding D Sheehan JP A practical grading scale for predicting outcome after radiosurgery for arteriovenous malformations: analysis of 1012 treated patients.J Neurosurg. 2013; 119: 981-987Crossref PubMed Scopus (179) Google Scholar The delayed course of radiation-induced obliteration could surpass the duration of ARUBA. Therefore, an unknown but large percentage of arteriovenous malformations in the interventional group were not cured, and morbidity could be due to both treatment and natural history. The authors should report cure rates. The trial's primary endpoint is the composite of death or stroke, defined as “any new focal neurological deficit, seizure, or new-onset headache” associated with imaging findings.1Mohr JP Parides MK Stapf C et al.Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial.Lancet. 2014; 383: 614-621Summary Full Text Full Text PDF PubMed Scopus (770) Google Scholar These definitions overestimate treatment morbidity. A post-intervention headache or seizure with oedema or hint of blood after embolisation could be counted as a stroke without causing permanent morbidity. An unknown but possibly large percentage of patients who reached the primary endpoint might have had minimum neurological effects, thereby misrepresenting risks. The authors should report modified Rankin scores. Microsurgical resection in selected patients with low Spetzler-Martin grades remains an effective, safe, immediate, and curative therapy for arteriovenous malformations. Efforts to show surgery's gold standard5Knopman J Stieg PE Management of unruptured brain arteriovenous malformations.Lancet. 2014; 383: 581-583Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar status are continuing. As we determine the trial's effect on clinical practice, we should not overgeneralise the results to microsurgery. We declare that we have no competing interests. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trialThe 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. Full-Text PDF Management of brain arteriovenous malformations – Authors' replyARUBA1 is the first-ever randomised controlled trial comparing clinical outcome in patients with unruptured brain arteriovenous malformations managed either with or without preventive interventional therapy. The as-treated analysis showed a more than 5-fold increased risk of primary outcome events (ie, death or symptomatic stroke) for patients undergoing invasive therapy (hazard ratio 5·26, 95% CI 2·63–11·11), as well as a significantly increased risk of, at times, devastating neurological deficits after intervention (relative risk 2·77, 95% CI 1·20–6·25). Full-Text PDF