Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

Salman, Rustam Al-Shahi; White, Phil; Counsell, Carl; Plessis, Johann du; Beijnum, Janneke van; Josephson, Colin B.; Wilkinson, Tim; Wedderburn, Catherine J.; Chandy, Zoe; George, Elena S.; Sellar, Robin; Warlow, Charles

doi:10.1001/jama.2014.3200

Cited by 193 publications

(56 citation statements)

References 30 publications

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“…(2012) were able to show that early surgical resection was associated with better overall survival than initial biopsy and watchful waiting. Another population‐based study from Scotland on patients with unruptured brain arteriovenous malformations showed that conservative management was associated with better clinical outcomes than treatment interventions (Salman et al., 2014). Using prospectively collected data from the Norwegian Registry for Spine Surgery, Nerland and coauthors were able to demonstrate that the effectiveness of laminectomy and microdecompression was equivalent in the management of lumbar spinal stenosis (Nerland et al., 2015).…”

Section: Discussionmentioning

confidence: 99%

“…Data from these registries can be used in epidemiological studies as they are easily obtained, include high number of patients, and provide both high external validity and statistical power (Jakola et al., 2012; Nerland et al., 2015; Salman et al., 2014; Sorensen, 1997). Administrative health registries need to have accurate diagnoses and sufficient coverage in the population they serve in order to be useful in research.…”

Section: Introductionmentioning

confidence: 99%

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Validation of intracranial hemorrhage in the Norwegian Patient Registry

et al. 2018

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ObjectivesAdministrative health registries need to have accurate diagnoses and sufficient coverage in the population they serve in order to be useful in research. In this study, we investigated the proportion of discharge diagnoses of intracranial hemorrhage (ICH) that were coded correctly in the Norwegian Patient Registry (NPR).Materials and MethodsWe reviewed the electronic medical records and diagnostic imaging of all admissions to St. Olavs University Hospital, Trondheim, Norway, between January 1, 2008, to December 31, 2014, with a discharge diagnosis of ICH in the NPR, and estimated positive predictive values (PPVs) for primary and secondary diagnoses. Separate calculations were made for inpatient and outpatient admissions.ResultsIn total, 1,419 patients with 1,458 discharge diagnoses of ICH were included in our study. Overall, 1,333 (91.4%) discharge diagnoses were coded correctly. For inpatient admissions, the PPVs for primary discharge codes were 96.9% for hemorrhagic stroke, 95.3% for subarachnoid hemorrhage, and 97.9% for subdural hemorrhage. The most common cause of incorrect diagnosis was previous stroke that should have been coded as rehabilitation or sequela after stroke. There were more false‐positive diagnoses among outpatient consultations and secondary diagnoses.ConclusionCoding of ICH discharge diagnoses in the NPR is of high quality, showing that data from this registry can safely be used for medical research.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Validation of intracranial hemorrhage in the Norwegian Patient Registry

et al. 2018

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“…4,5,19 The notion that patients with unruptured AVMs can be harmed by intervention more than conservative management was suggested by the early analysis of ARUBA, as well as by the prospective, observational AVM cohort study from the Scottish Audit of Intracranial Vascular Malformations. 12,20 ARUBA has been appropriately scrutinized for its numerous methodological weaknesses. 13 By analyzing a multicenter cohort of ARUBA-eligible patients treated with radiosurgery alone, we endeavor to address some of these weaknesses.…”

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

Stroke

115

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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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“…[1][2][3] In patients with ruptured AVMs, the annual risk of rebleeding has been estimated to be between 3.7% and 7.5%. [4][5][6][7][8][9][10] Radical treatment, including surgical excision, radiosurgery, endovascular treatment, and combinations of these procedures, is considered when the risks associated to a therapeutic intervention are estimated to be lower than the accumulated risks of the outcomes of AVM-related cerebral hemorrhage. 2 In contrast, for patients with an unruptured AVM, therapeutic intervention remains uncertain because the expected risk for cerebral hemorrhage with the natural history of AVMs largely depends on the characteristics of the patients selected for observation and on the definition of the starting point of observation.…”

mentioning

confidence: 99%

“…The annual bleeding risk of observed AVMs has been reported to be relatively low, ranging between 1.3% and 4.0%, even when the period of observation has been limited to the time from diagnosis to the last follow-up. [4][5][6][7][8][9][10] Therefore, there is a significant clinical controversy around recommendation of invasive interventions of AVMs, considering their relatively benign natural course.…”

mentioning

confidence: 99%

Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations

Hanakita

Shin

Koga

et al. 2016

Stroke

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Methods-A retrospective review was performed for 292 patients with unruptured arteriovenous malformations referred for SRS. The risks for cerebral hemorrhages were statistically compared before and after SRS. Results-Of the 292 patients in whom arteriovenous malformation was found unruptured at initial diagnosis, 17 sustained hemorrhages in the period between the diagnosis and the initial therapeutic intervention (annual bleeding rate, 2.1%; 95% confidence interval [CI], 1.2%-3.4%). Of the remaining 275 patients, 240 were initially treated with SRS, and 16 sustained a hemorrhage after SRS (annual bleeding rate, 1.1%; 95% CI, 0.6%-1.8%), but only 2 sustained a hemorrhage after angiographic obliteration (annual bleeding rate, 0.3%; 95% CI, 0.04%-1.2%

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Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

Abstract: Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.

Cited by 193 publications

References 30 publications

Validation of intracranial hemorrhage in the Norwegian Patient Registry

Validation of intracranial hemorrhage in the Norwegian Patient Registry

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

Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations

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