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Ding D, Starke RM, Kano H, Mathieu D, Huang P, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Radiosurgery for Cerebral Arteriovenous Malformations in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)-Eligible Patients: A Multicenter Study. Stroke 2015; 47:342-9. [PMID: 26658441 DOI: 10.1161/strokeaha.115.011400] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/05/2015] [Indexed: 11/16/2022]
Abstract
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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Affiliation(s)
- Dale Ding
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Robert M Starke
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Hideyuki Kano
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - David Mathieu
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Paul Huang
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Douglas Kondziolka
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Caleb Feliciano
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Rafael Rodriguez-Mercado
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Luis Almodovar
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Inga S Grills
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Danilo Silva
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Mahmoud Abbassy
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Symeon Missios
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Gene H Barnett
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - L Dade Lunsford
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Jason P Sheehan
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
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