The Risk of Stroke or Clinical Impairment After Stereotactic Radiosurgery for ARUBA-Eligible Patients

Pollock, Bruce E.; Link, Michael J.; Brown, Robert D.

doi:10.1161/strokeaha.112.670232

Cited by 60 publications

(30 citation statements)

References 39 publications

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“…However, ARUBA was criticized because of its low enrollment rate, small sample size, short follow-up, high rate of adverse outcomes, under-representation of surgical treatment, and lack of treatment stratification. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Its primary outcome after interventional treatment was higher than in previous cohorts treated with microsurgery or radiosurgery [23][24][25][26][27][28][29] without a clear explanation. It combined 3 different interventions into a single amorphous category and did not discriminate which modality was harmful.…”

Section: Discussionmentioning

confidence: 79%

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Wong

Slomovic

Ibrahim

et al. 2017

Stroke

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Background and Purpose-The management of unruptured brain arteriovenous malformations (ubAVMs) remains controversial despite ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation), a controlled trial that suggested superiority of conservative management over intervention. However, microsurgery occurred in only 14.9% of ARUBA intervention cases, raising concerns about the study's generalizability. Our purpose was to evaluate whether, in a larger ARUBA-eligible ubAVM population, microsurgery produces acceptable outcomes. Methods-Demographic data, AVM characteristics, and treatment outcomes were evaluated in 155 ARUBA-eligible bAVMs treated with microsurgery between 1994 and 2014. Outcomes were rates of early disabling deficits and permanent disabling deficits with modified Rankin Scale score ≥3 or any permanent neurological deficits with modified Rankin Scale score ≥1. Covariates associated with outcomes were determined by regression analysis. Results-Of

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Section: Discussionmentioning

confidence: 79%

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Wong

Slomovic

Ibrahim

et al. 2017

Stroke

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“…Previous studies have also reported reasonably good outcomes after AVM resection and radiosurgery in ARUBAeligible patients, although these analyses were performed in single-center cohorts. [47][48][49] A crude comparison of our rates of unfavorable treatment outcome and adverse neurological outcome to the rates of the primary end point (death or symptomatic stroke) in the interventional and medical arms of ARUBA does not definitively support the use of radiosurgery for unruptured patients with AVM (Table II in the online-only Data Supplement). However, one should note that persistent AVM patency after radiosurgery was a significant contributor to the designation of unfavorable outcome in our analysis.…”

Section: February 2016mentioning

confidence: 89%

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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“…The ARUBA trial showed that interventional therapy is inferior compared with medical treatment of previously unruptured brain AVMs [6] . However, this study mixed together interventional therapies of fundamentally different qualities such as open neurosurgery, embolization and stereotactic radiosurgery and the avoidance of interventional treatment for all patients with unruptured brain AVMs was questioned [7][8][9] . The group with large AVMs also represents an unfavorable subgroup of patients, with a higher risk of subsequent hemorrhage [10] .…”

Section: Discussionmentioning

confidence: 99%

Radiosurgery for Large Arteriovenous Malformations as a Single-Session or Staged Treatment

Chytka

Kozubíková²,

Vymazal³

2015

Stereotact Funct Neurosurg

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Background/Objectives: The treatment of large arteriovenous malformations (AVMs) presents a challenge and the effectiveness of radiosurgery decreases with increasing treatment volume. Here, we analyzed and compared single-session treatment for AVMs >15 cm³ with staged treatment, when the volume of a large AVM was divided into 2 or more compartments, which were subsequently treated at intervals of a few months. In the event that complete obliteration was not achieved within 3 years, repeat radiosurgery was considered. Methods/Results: Between 1993 and 2011, gamma-knife radiosurgery was performed on 50 patients with large AVMs. A total of 27 of them, with volumes ranging from 15.1 to 27 cm³ (median = 17.8), were treated in a single session, with a marginal dose ranging from 10 to 17 Gy (median = 15). Complete obliteration was achieved in 7 (26%) of these; in 14 patients the treatment was repeated after a median of 38 months. The volume of AVMs subjected to repeat treatment regressed and ranged from 6.76 to 16.4 cm³ (median = 7.7), with the marginal dose ranging from 13 to 18 Gy (median = 17); 10 patients later achieved complete obliteration at a median of 79 months after the initial treatment. Overall, 63% of patients achieved complete obliteration of AVM after treatment. Rebleeding in a latent period was recorded in 3 patients (11%) and symptomatic collateral edema in 2 (7%); 23 patients were treated using the staged method, with the interval between staged treatments usually being 6 months. Their overall AVM volume ranged from 13.2 to 46.6 cm³ (median = 23.3), the volume for a single stage ranged from 4.5 to 31.3 cm³ (median 11.7), and the marginal dose ranged from 10 to 18 Gy (median = 17). Complete obliteration was achieved in 4 (17%) of them, in 8 patients the treatment was repeated at a median of 53 months after the first treatment, and a third retreatment was performed on 2 patients 98 and 102 months, respectively, after the first treatment. The volume for repeated treatment of AVMs ranged from 0.81 to 7.7 cm³ (median = 3.3), with the marginal dose ranging from 14 to 20 Gy (median 17.5). Of all the retreated patients, 5 AVMs subsequently achieved complete obliteration. Overall, 9 patients (39%) were totally cured. Rebleeding in a latent period was observed in 1 of these patients (4.3%) and symptomatic edema in another 1 (4.3%). Conclusions: Radiosurgery of large AVMs is a valuable treatment either as a single-session or staged treatment, with a reasonable chance of cure and a low risk of complications.

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The Risk of Stroke or Clinical Impairment After Stereotactic Radiosurgery for ARUBA-Eligible Patients

Cited by 60 publications

References 39 publications

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

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

Radiosurgery for Large Arteriovenous Malformations as a Single-Session or Staged Treatment

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