Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial

Mohr, J. P.; Overbey, Jessica; Hartmann, Andreas; Kummer, Rüdiger von; Salman, Rustam Al-Shahi; Kim, Helen; Worp, H. Bart van der; Parides, Michael K.; Stefani, Marco Antônio; Houdart, Emmanuel; Libman, Richard B.; Pile‐Spellman, John; Harkness, Kirsty; Cordonnier, Charlotte; Moquete, Ellen; Biondi, Alessandra; Klijn, Catharina J.M.; Stapf, Christian; Moskowitz, Alan J.

doi:10.1016/s1474-4422(20)30181-2

Cited by 119 publications

(63 citation statements)

References 27 publications

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“…A thorough investigation of literature ensures the applicability of recommendations in these guidelines to the ruptured bAVMs. For unruptured bAVMs, conservative treatment was proposed to result in significantly lower risks of death or stroke and better outcomes than surgical treatments ( 97 , 304 ). ARUBA is the first randomized trial of unruptured bAVMs to better understand their natural history and associated treatment risks, however, it is controversial for its results.…”

Section: Resultsmentioning

confidence: 99%

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

et al. 2021

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Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas.Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association.Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III.Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.

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Section: Resultsmentioning

confidence: 99%

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

et al. 2021

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“…observation with pharmacological therapy for neurological symptoms as needed) [ 4 ], whereby no definitive treatment guidelines exist [ 34 ]. 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 ].…”

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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“…In 2016, a 5‐year follow‐up data showed favorable outcomes in the medical group again, with exception of radiosurgery which showed a benefit of treatment 31 . Recently the investigators extended the follow‐up time and again data show that interventional management might pose extra risk in the long‐run 32 …”

Section: Intracranial Vascular Lesionsmentioning

confidence: 99%

Central nervous system vascular malformations: A clinical review

Sabayan

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Viswanathan

et al. 2021

Ann Clin Transl Neurol

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CNS vascular malformation is an umbrella term that encompasses a wide variety of pathologies, with a wide range of therapeutic and diagnostic importance. This range spans lesions with a risk of devastating neurological compromise to lesions with a slow, static or benign course. Advances in neurovascular imaging along with increased utilization of these advances, have resulted in more frequent identification of these lesions. In this article, we provide an overview on definitions and classifications of CNS vascular malformations and outline the etiologic, diagnostic, prognostic, and therapeutic features for each entity. This review covers intracranial and spinal cord vascular malformations and discusses syndromes associated with CNS vascular malformations.

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Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial

Abstract: The Lancet Neurology Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, open, parallel group, randomised controlled trial

Cited by 119 publications

References 27 publications

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

Controlled arterial hypotension during resection of cerebral arteriovenous malformations

Central nervous system vascular malformations: A clinical review

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