Recommendations for the Management of Intracranial Arteriovenous Malformations

Ogilvy, Christopher S.; Stieg, Philip E.; Awad, Issam A.; Brown, Robert D.; Kondziolka, Douglas; Rosenwasser, Robert H.; Young, William L.; Hádemenos, George J.

doi:10.1161/01.str.32.6.1458

Cited by 459 publications

(95 citation statements)

References 177 publications

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“…Both interventional eradication and conservative follow-up are recognised management strategies in patients with brain arteriovenous malformations. 16,17 As far as we are aware, ARUBA is the first randomised controlled clinical trial assessing the outcomes from these two management strategies (ie, medical management with interventional therapy or medical management alone) in patients diagnosed with an unruptured brain arteriovenous malformation (panel). 18 …”

Section: Discussionmentioning

confidence: 99%

Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial

et al. 2014

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Summary Background The clinical benefit of preventive eradication of unruptured brain arteriovenous malformations remains uncertain. A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA) aims to compare the risk of death and symptomatic stroke in patients with an unruptured brain arteriovenous malformation who are allocated to either medical management alone or medical management with interventional therapy. Methods Adult patients (≥18 years) with an unruptured brain arteriovenous malformation were enrolled into this trial at 39 clinical sites in nine countries. Patients were randomised (by web-based system, in a 1:1 ratio, with random permuted block design [block size 2, 4, or 6], stratified by clinical site) to medical management with interventional therapy (ie, neurosurgery, embolisation, or stereotactic radiotherapy, alone or in combination) or medical management alone (ie, pharmacological therapy for neurological symptoms as needed). Patients, clinicians, and investigators are aware of treatment assignment. The primary outcome is time to the composite endpoint of death or symptomatic stroke; the primary analysis is by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00389181. Findings Randomisation was started on April 4, 2007, and was stopped on April 15, 2013, when a data and safety monitoring board appointed by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health recommended halting randomisation because of superiority of the medical management group (log-rank Z statistic of 4·10, exceeding the prespecified stopping boundary value of 2·87). At this point, outcome data were available for 223 patients (mean follow-up 33·3 months [SD 19·7]), 114 assigned to interventional therapy and 109 to medical management. The primary endpoint had been reached by 11 (10·1%) patients in the medical management group compared with 35 (30·7%) in the interventional therapy group. The risk of death or stroke was significantly lower in the medical management group than in the interventional therapy group (hazard ratio 0·27, 95% CI 0·14–0·54). No harms were identified, other than a higher number of strokes (45 vs 12, p<0·0001) and neurological deficits unrelated to stroke (14 vs 1, p=0·0008) in patients allocated to interventional therapy compared with medical management. Interpretation The 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. Funding National Institutes of Health, National Institute of Neurological Disorders and Stroke.

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Section: Discussionmentioning

confidence: 99%

Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial

et al. 2014

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“…Although surgical resection remains the standard for the definitive eradication of most brain AVMs, endovascular embolization has the potential to enhance the safety and efficacy of AVM treatment when applied as adjuvant therapy before microsurgery (table 3) [4,5,6,7,8]. Preoperative embolization of AVMs has been shown to reduce operation time and intraoperative blood loss, with no difference in surgical complications or long-term neurological outcome [39].…”

Section: Embolization Of Brain Avmsmentioning

confidence: 99%

“…The indication for palliative embolization is usually acute hemorrhage. Embolization under these circumstances should be used to treat specific high-risk AVM angioarchitectural features such as aneurysms, or to alleviate specific clinical signs and symptoms related to vascular steal and/or mechanical compression [4,55,56]. Partial embolization may also be beneficial in patients with medically refractory seizures or with progressive neurological deficits thought to be secondary to venous hypertension or arterial ‘steal' phenomenon causing ischemia.…”

Section: Embolization Of Brain Avmsmentioning

confidence: 99%

“…Partial embolization may also be beneficial in patients with medically refractory seizures or with progressive neurological deficits thought to be secondary to venous hypertension or arterial ‘steal' phenomenon causing ischemia. Palliative embolization is not recommended as a broad treatment strategy for inoperable lesions as it does not appear to produce better clinical results than medical management and there is no evidence to suggest that partial AVM embolization alters long-term hemorrhagic risk [4,57,58]. On the contrary, partial embolization has been shown to worsen the clinical course of the patient compared with the natural history of an untreated lesion [59].…”

Section: Embolization Of Brain Avmsmentioning

confidence: 99%

“…Endovascular treatment is directed at particularly ‘weak points' within the AVM, including flow-related aneurysms and high-flow fistulae, with the aim to decrease lesion volume and establish more normal blood flow patterns within surrounding brain parenchyma [2]. In cases of nonsurgical or nonradiosurgical AVMs, palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function [3,4,5,6,7,8]. Less frequently, embolization is used as ‘primary therapy' particularly for smaller, surgically difficult lesions.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Endovascular Management of Arteriovenous Malformations of the Brain

Bruno¹,

Meyers

2012

Intervent Neurol

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Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as ‘primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.

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