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Raymond J, Fahed R, Darsaut TE. Ethical Problems of Observational Studies and Big Data Compared to Randomized Trials. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:389-398. [PMID: 38739037 DOI: 10.1093/jmp/jhae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
The temptation to use prospective observational studies (POS) instead of conducting difficult trials (RCTs) has always existed, but with the advent of powerful computers and large databases, it can become almost irresistible. We examine the potential consequences, were this to occur, by comparing two hypothetical studies of a new treatment: one RCT, and one POS. The POS inevitably submits more patients to inferior research methodology. In RCTs, patients are clearly informed of the research context, and 1:1 randomized allocation between experimental and validated treatment balances risks for each patient. In POS, for each patient, the risks of receiving inferior treatment are impossible to estimate. The research context and the uncertainty are down-played, and patients and clinicians are at risk of becoming passive research subjects in studies performed from an outsider's view, which potentially has extraneous objectives, and is conducted without their explicit, autonomous, and voluntary involvement and consent.
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Affiliation(s)
- Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Robert Fahed
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
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2
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Darsaut TE, Findlay JM, Bojanowski MW, Chalaala C, Iancu D, Roy D, Weill A, Boisseau W, Diouf A, Magro E, Kotowski M, Keough MB, Estrade L, Bricout N, Lejeune JP, Chow MMC, O'Kelly CJ, Rempel JL, Ashforth RA, Lesiuk H, Sinclair J, Erdenebold UE, Wong JH, Scholtes F, Martin D, Otto B, Bilocq A, Truffer E, Butcher K, Fox AJ, Arthur AS, Létourneau-Guillon L, Guilbert F, Chagnon M, Zehr J, Farzin B, Gevry G, Raymond J. A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2023; 44:634-640. [PMID: 37169541 PMCID: PMC10249696 DOI: 10.3174/ajnr.a7865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND PURPOSE Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.
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Affiliation(s)
- T E Darsaut
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J M Findlay
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | | | | | - D Iancu
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - D Roy
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Weill
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - W Boisseau
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - A Diouf
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - E Magro
- Service of Neurosurgery (E.M.), Centre Hospitalier Universitaire Cavale Blanche, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1101 LaTIM, Brest, France
| | - M Kotowski
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M B Keough
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - L Estrade
- Interventional Neuroradiology (L.E., N.B.)
| | - N Bricout
- Interventional Neuroradiology (L.E., N.B.)
| | - J-P Lejeune
- Service of Neurosurgery (J.-P.L.), Centre Hospitalier Universitaire de Lille, Lille, France
| | - M M C Chow
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - C J O'Kelly
- From the Division of Neurosurgery (T.E.D., J.M.F., M.B.K., M.M.C.C., C.J.O.)
| | - J L Rempel
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - R A Ashforth
- Department of Surgery, and Department of Radiology and Diagnostic Imaging (J.L.R., R.A.A.), Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - H Lesiuk
- Section of Neurosurgery (H.L., J.S.)
| | | | - U-E Erdenebold
- Department of Surgery, and Department of Medical Imaging (U.-E.E.), Section of Interventional Neuroradiology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J H Wong
- Division of Neurosurgery (J.H.W.), Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - F Scholtes
- Departments of Neurosurgery (F.S., D.M.)
| | - D Martin
- Departments of Neurosurgery (F.S., D.M.)
| | - B Otto
- Medical Physics (B.O.), Division of Medical Imaging, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - A Bilocq
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - E Truffer
- Service of Neurosurgery (A.B., E.T.), Centre Hospitalier Régional de Trois-Rivières, Trois-Rivières, Québec, Canada
| | - K Butcher
- Clinical Neurosciences (K.B.), Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - A J Fox
- Department of Medical Imaging (A.J.F.), University of Toronto, Toronto, Ontario, Canada
| | - A S Arthur
- Department of Neurosurgery (A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| | - L Létourneau-Guillon
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - F Guilbert
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montréal, Québec, Canada
| | - B Farzin
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - G Gevry
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
| | - J Raymond
- Department of Surgery, and Service of Neuroradiology (D.I., D.R., A.W., W.B., A.D., M.K., L.L.-G., F.G., J.R.), Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
- Research Centre of the University of Montreal Hospital Centre (B.F., G.G., J.R.), Interventional Neuroradiology Research Laboratory, Montreal, Québec, Canada
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Raymond J, Benomar A, Gentric JC, Magro E, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Bojanowski MW, Chaalala C, Eker O, Pelissou-Guyotat I, Piotin M, Aldea S, Barbier C, Gaberel T, Papagiannaki C, Derrey S, Nguyen TN, Abdalkader M, Cognard C, Januel AC, Sabatier JF, Jecko V, Barreau X, Costalat V, Le Corre M, Gauvrit JY, Morandi X, Biondi A, Thines L, Desal H, Bourcier R, Beaujeux R, Proust F, Viard G, Gevry G, Darsaut TE. Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations. World Neurosurg 2023; 172:e611-e624. [PMID: 36738962 DOI: 10.1016/j.wneu.2023.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients. METHODS The first randomized clinical trial (RCT-1) offers 1:1 randomized allocation of intervention versus conservative management for patients with arteriovenous malformation (AVM). The second randomized clinical trial (RCT-2) allocates 1:1 pre-embolization or no pre-embolization to surgery or radiosurgery patients judged treatable with or without embolization. Characteristics of RCT patients are reported and compared to registry patients. RESULTS From June 2014 to May 2021, 1010 patients with AVM were recruited; 498 patients were observed and 373 were included in the treatment registries. Randomized allocation in RCT-1 was applied to 139 (26%) of the 512 patients (including 127 of 222 [57%] with unruptured AVMs) considered for curative treatment. RCT-1 AVM patients differed (in rupture status, Spetzler-Martin grade and baseline modified Rankin Score) from those in the observation or treatment registries (P < 0.001). Most patients had small (<3 cm; 71%) low-grade (Spetzler-Martin I-II; 64%) unruptured (91%) AVMs. The allocated management was conservative (n = 71) or curative (n = 68), using surgery (n = 39), embolization (n = 16), or stereotactic radiosurgery (n = 13). Pre-embolization was considered for 179/309 (58%) patients allocated/assigned to surgery or stereotactic radiosurgery; 87/179 (49%) were included in RCT-2. RCT-2 patient AVMs differed in size, eloquence and grade from patients of the pre-embolization registry (P < 0.01). Most had small (<3 cm in 82%) low-grade (83%) AVMs in non-eloquent brain (64%). CONCLUSIONS Patients included in the RCTs differ significantly from registry patients. Meaningful results can be obtained if multiple centers actively participate in the TOBAS RCTs.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| | - Anass Benomar
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | | | - Elsa Magro
- Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Lorena Nico
- Service de Neuroradiologie Interventionnelle, CHU Saint-Etienne, Saint-Étienne, France
| | - Emma Bacchus
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Laboratoire de Recherche en NeuroRadiologie Interventionnelle (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Omer Eker
- Service d'imagerie neurologique diagnostique et interventionnelle, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Lyon, France
| | - Isabelle Pelissou-Guyotat
- Service de Neurochirurgie Tumorale et Vasculaire, Hôpital neurologique Pierre Wertheimer, Hospices civils de Lyon, Lyon, France
| | - Michel Piotin
- Service de Neuroradiologie Interventionnelle, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Sorin Aldea
- Service de Neurochirurgie, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Charlotte Barbier
- Service d'imagerie vasculaire et Interventionnelle, CHU Caen Normandie, Caen, France
| | - Thomas Gaberel
- Service de neurochirurgie, CHU Caen Normandie, Caen, France
| | | | - Stéphane Derrey
- Service de Neurochirurgie, Hôpital Charles Nicolle, CHU Rouen Normandie, Rouen France
| | - Thanh N Nguyen
- Department of Radiology, Department of Neurology, Department of Neurosurgery, Boston Medical Center, Boston University-School of Medicine, Boston, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University-School of Medicine, Boston, USA
| | - Christophe Cognard
- Service de Neuroradiolgie diagnostique et thérapeutique, Hôpital Pierre-Paul Riquet, CHU de Toulouse, France
| | - Anne-Christine Januel
- Service de Neuroradiolgie diagnostique et thérapeutique, Hôpital Pierre-Paul Riquet, CHU de Toulouse, France
| | - Jean-François Sabatier
- Service de Neurochirurgie, Hôpital Pierre-Paul Riquet, CHU de Toulouse, Toulouse, France
| | - Vincent Jecko
- Service de Neurochirurgie A, Groupe Hospitalier Pellegrin, CHU Bordeaux, Bordeaux France
| | - Xavier Barreau
- Service de Neuroradiologie Diagnostique et Thérapeutique, Groupe Hospitalier Pellegrin, CHU Bordeaux, Bordeaux France
| | - Vincent Costalat
- Service de Neuroradiologie, CHU Montpellier, Montpellier, France
| | - Marine Le Corre
- Service de Neurochirurgie, CHU Montpellier, Montpellier, France
| | - Jean-Yves Gauvrit
- Service de neuroradiologie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Xavier Morandi
- Service de neurochirurgie, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Alessandra Biondi
- Department of Interventional Neuroradiology, University Hospital Centre Besancon, Besancon, France
| | - Laurent Thines
- Department of Neurosurgery, University Hospital Jean Minjoz, Besançon, France
| | - Hubert Desal
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Rémy Beaujeux
- Service de Neuroradiologie Interventionnelle,Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - François Proust
- Service de Neurochirurgie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Guylaine Gevry
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Laboratoire de Recherche en NeuroRadiologie Interventionnelle (NRI), Montreal, Quebec, Canada
| | - Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Raymond J, Gentric JC, Magro E, Nico L, Bacchus E, Klink R, Cognard C, Januel AC, Sabatier JF, Iancu D, Weill A, Roy D, Bojanowski MW, Chaalala C, Barreau X, Jecko V, Papagiannaki C, Derrey S, Shotar E, Cornu P, Eker OF, Pelissou-Guyotat I, Piotin M, Aldea S, Beaujeux R, Proust F, Anxionnat R, Costalat V, Corre ML, Gauvrit JY, Morandi X, Brunel H, Roche PH, Graillon T, Chabert E, Herbreteau D, Desal H, Trystram D, Barbier C, Gaberel T, Nguyen TN, Viard G, Gevry G, Darsaut TE, _ _, _ _, Raymond J, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Darsaut TE, O’Kelly CJ, Chow MMC, Findlay JM, Rempel JL, Fahed R, Lesiuk H, Drake B, Santos MD, Gentric JC, Nonent M, Ognard J, El-Aouni MC, Magro E, Seizeur R, Timsit S, Pradier O, Desal H, Boursier R, Thillays F, Roualdes V, Piotin M, Blanc R, Aldea S, Cognard C, Januel AC, Sabatier JF, Calviere L, Gauvrit JY, Raoult H, Eugene F, Bras AL, Ferre JC, Paya C, Morandi X, Lecouillard I, Nouhaud E, Ronziere T, Trystram D, Naggara O, Rodriguez-Regent C, Kerleroux B, Barbier C, Gaberel T, Emery E, Touze E, Papagiannaki C, Derrey S, Eker OF, Riva R, Pellisou-Guyotat I, Guyotat J, Berhouma M, Dumot C, Biondi A, Thines L, Bougaci N, Charbonnier G, Bracard S, Anxionnat R, Gory B, Civit T, Bernier-Chastagner V, Barreau X, Marnat G, Jecko V, Penchet G, Gimbert E, Huchet A, Herbreteau D, Boulouis G, Bibi R, Ifergan H, Janot K, Velut S, Brunel H, Roche PH, Graillon T, Peyriere H, Kaya JM, Touta A, Troude L, Boissonneau S, Clarençon F, Shotar E, Sourour N, Lenck S, Premat K, Boch AL, Cornu P, Nouet A, Costalat V, Bonafe A, Dargazanli C, Gascou G, Lefevre PH, Riquelme C, Corre ML, Beaujeux R, Pop R, Proust F, Cebula H, Ollivier I, Spatola G, Spell L, Chalumeau V, Gallas S, Ikka L, Mihalea C, Ozanne A, Caroff J, Chabert E, Mounayer C, Rouchaud A, Caire F, Ricolfi F, Thouant P, Cao C, Mourier KL, Farah W, Nguyen TN, Abdalkader M, Huynh T, Tawk RG, Carlson AP, Silva LAO, Froio NDL, Silva GS, Mont’Alverne FJA, Martins JL, Mendes GN, Miranda RR. Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:1393-1402. [PMID: 37132535 DOI: 10.3171/2022.9.jns22987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.
METHODS
Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.
RESULTS
From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%).
CONCLUSIONS
Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | - Elsa Magro
- Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Lorena Nico
- Department of Radiology, CHU Saint-Etienne, France
| | - Emma Bacchus
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | | | - Jean-François Sabatier
- Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Daniela Iancu
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Michel W. Bojanowski
- Department of Surgery, Division of Neurosurgery, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Chiraz Chaalala
- Department of Surgery, Division of Neurosurgery, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Xavier Barreau
- Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, France
| | - Vincent Jecko
- Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, France
| | | | - Stéphane Derrey
- Neurosurgery, Charles Nicolle Hospital, Rouen Normandy University Hospital, Rouen, France
| | | | - Philippe Cornu
- Neurosurgery, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | | | | | - Sorin Aldea
- Neurosurgery, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - François Proust
- Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - René Anxionnat
- Interventional Neuroradiology Department, University of Lorraine, Laboratory IADI INSERM U1254, CHRU Nancy, France
| | | | | | | | | | - Hervé Brunel
- Departments of Interventional Neuroradiology and
| | | | | | - Emmanuel Chabert
- Interventional Neuroradiology Department, CHU Clermont-Ferrand, France
| | - Denis Herbreteau
- Interventional Neuroradiology Department, Bretonneau Hospital, Tours, France
| | - Hubert Desal
- Interventional Neuroradiology Department, CHU de Nantes, France
| | - Denis Trystram
- Interventional Neuroradiology Department, University of Paris, INSERM U1266, IPNP, GHU Paris, France
- Psychiatry and Neurosciences, Sainte-Anne Hospital, Paris, France
| | | | | | - Thanh N. Nguyen
- Departments of Radiology,
- Neurology, and
- Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; and
| | | | - Guylaine Gevry
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Tim E. Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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5
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Darsaut TE, Magro E, Bojanowski MW, Chaalala C, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Sabatier JF, Cognard C, Januel AC, Pelissou-Guyotat I, Eker O, Roche PH, Graillon T, Brunel H, Proust F, Beaujeux R, Aldea S, Piotin M, Cornu P, Shotar E, Gaberel T, Barbier C, Corre ML, Costalat V, Jecko V, Barreau X, Morandi X, Gauvrit JY, Derrey S, Papagiannaki C, Nguyen TN, Abdalkader M, Tawk RG, Huynh T, Viard G, Gevry G, Gentric JC, Raymond J. Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:891-899. [PMID: 36087316 DOI: 10.3171/2022.7.jns22813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).
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Affiliation(s)
- Tim E Darsaut
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Elsa Magro
- 2Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Michel W Bojanowski
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Lorena Nico
- 4Division of Interventional Neuroradiology, Department of Radiology, CHU Saint-Etienne, North Hospital, Saint-Etienne, France
| | - Emma Bacchus
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Jean-Francois Sabatier
- 7Department of Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Christophe Cognard
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Anne-Christine Januel
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | | | - Omer Eker
- 10Diagnostic and Interventional Neurological Imaging, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Thomas Graillon
- 12Department of Neurosurgery, Aix Marseille University, INSERM, AP-HM, MMG, UMR1251, Marmara Institute, La Timone Hospital, Marseille, France
| | - Hervé Brunel
- 13Department of Neuroradiology, La Timone Hospital, AP-HM, Marseille, France
| | - Francois Proust
- 14Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- 15Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France
| | | | - Michel Piotin
- 17Interventional Radiology, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - Eimad Shotar
- 19Neuroradiology, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | - Charlotte Barbier
- 21Vascular and Interventional Imaging, CHU Caen Normandie, Caen, France
| | | | | | - Vincent Jecko
- 24Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- 25Diagnostic and Therapeutic Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | | | - Jean-Yves Gauvrit
- 27Neuroradiology, Pontchaillou Hospital, Rennes University Hospital, Rennes, France
| | | | | | - Thanh N Nguyen
- Departments of30Radiology.,31Neurology, and.,32Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Thien Huynh
- 34Radiology, Mayo Clinic, Jacksonville, Florida
| | - Geraldine Viard
- 35Clinical Investigation Center, CHU Brest, Brest, France; and
| | - Guylaine Gevry
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- 36Department of Interventional Neuroradiology, Cavale Blanche Hospital, Brest University Hospital, Brest, France
| | - Jean Raymond
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada.,6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
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6
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Raymond J, Iancu D, Boisseau W, Diestro JDB, Klink R, Chagnon M, Zehr J, Drake B, Lesiuk H, Weill A, Roy D, Bojanowski MW, Chaalala C, Rempel JL, O'Kelly C, Chow MM, Bracard S, Darsaut TE. Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial. AJNR Am J Neuroradiol 2022; 43:1244-1251. [PMID: 35926886 PMCID: PMC9451626 DOI: 10.3174/ajnr.a7597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Flow diversion is a recent endovascular treatment for intracranial aneurysms. We compared the safety and efficacy of flow diversion with the alternative standard management options. MATERIALS AND METHODS A parallel group, prerandomized, controlled, open-label pragmatic trial was conducted in 3 Canadian centers. The trial included all patients considered for flow diversion. A Web-based platform 1:1 randomly allocated patients to flow diversion or 1 of 4 alternative standard management options (coiling with/without stent placement, parent vessel occlusion, surgical clipping, or observation) as prespecified by clinical judgment. Patients ineligible for alternative standard management options were treated with flow diversion in a registry. The primary safety outcome was death or dependency (mRS > 2) at 3 months. The composite primary efficacy outcome included the core lab-determined angiographic presence of a residual aneurysm, aneurysm rupture, progressive mass effect during follow-up, or death or dependency (mRS > 2) at 3-12 months. RESULTS Between May 2011 and November 2020, three hundred twenty-three patients were recruited: Two hundred seventy-eight patients (86%) had treatment randomly allocated (139 to flow diversion and 139 to alternative standard management options), and 45 (14%) received flow diversion in the registry. Patients in the randomized trial frequently had unruptured (83%), large (52% ≥10 mm) carotid (64%) aneurysms. Death or dependency at 3 months occurred in 16/138 patients who underwent flow diversion and 12/137 patients receiving alternative standard management options (relative risk, 1.33; 95% CI, 0.65-2.69; P = .439). A poor primary efficacy outcome was found in 30.9% (43/139) with flow diversion and 45.6% (62/136) of patients receiving alternative standard management options, with an absolute risk difference of 14.7% (95% CI, 3.3%-26.0%; relative risk, 0.68; 95% CI, 0.50-0.92; P = .014). CONCLUSIONS For patients with mostly unruptured, large, anterior circulation (carotid) aneurysms, flow diversion was more effective than the alternative standard management option in terms of angiographic outcome.
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Affiliation(s)
- J Raymond
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Iancu
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
- Departments of Radiology (D.I.)
| | - W Boisseau
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - J D B Diestro
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - R Klink
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M Chagnon
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - J Zehr
- Department of Mathematics and Statistics (M.C., J.Z.), Université de Montréal, Montreal, Canada
| | - B Drake
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - H Lesiuk
- Surgery (B.D., H.L.), Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
| | - A Weill
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - D Roy
- From the Department of Radiology (J.R., D.I., W.B., J.D.B.D., R.K., A.W., D.R.), Centre Hospitalier de l'Université de Montréal, Quebec, Canada
| | - M W Bojanowski
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - C Chaalala
- Department of Neurosurgery (M.W.B., C.C.), Centre Hospitalier de l'Université de Montréal, Notre-Dame Hospital, Montreal, Quebec, Canada
| | | | - C O'Kelly
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - M M Chow
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - S Bracard
- Neuroradiology (S.B.), CHRU de Nancy, Nancy, Lorraine, France
| | - T E Darsaut
- Surgery (C.O., M.M.C., T.E.D.), Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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Obaid S, Darsaut TE, Raymond J. Understanding the problems with recruitment in surgical randomized trials: A lesson from landmark trials on temporal lobe epilepsy. Neurochirurgie 2022; 68:612-617. [PMID: 35787925 DOI: 10.1016/j.neuchi.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical randomized trials are difficult to accomplish. One major problem is recruitment of a sufficient number of patients to address the clinical problem. METHODS We review the various ways patient recruitment in surgical RCTs can be promoted. We examine two landmark trials on the surgical treatment of temporal lobe epilepsy (TLE), one that was successful, and one which did not attain the target number of participants. DISCUSSION Both designs of the Canadian and American trials of surgery for TLE included a benefit to participants: the Canadian trial gave a chance to have immediate access to investigation and treatment, as compared to a 1 year delay (considered 'standard care' in that center), while the American trial offered free surgical management to both arms. Patients were recruited and treatments randomly allocated prior to knowing for certain whether they were surgical candidates or not. This design choice may have helped circumvent the 'equipoise problem'. The Canadian trial offered participation to drug-resistant patients that were already routinely referred to surgical centers, while the success of the American trial which limited recruitment to the early period of drug resistance was dependent on a change of practice of referring clinicians which did not materialize. CONCLUSION The surgical treatment of drug-resistant temporal lobe epilepsy has been validated using RCT methods. Ways to promote participation in surgical trials should be further investigated.
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Affiliation(s)
- S Obaid
- Department of Neurosurgery, Comprehensive Epilepsy Center, Yale School of Medicine, New Haven, CT, USA
| | - T E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Iancu D, Collins J, Farzin B, Darsaut TE, Eneling J, Boisseau W, Olijnyk L, Boulouis G, Chaalala C, Bojanowski MW, Weill A, Roy D, Raymond J. Recruitment in a pragmatic randomized trial on the management of unruptured intracranial aneurysms. World Neurosurg 2022; 163:e413-e419. [PMID: 35395427 DOI: 10.1016/j.wneu.2022.03.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage UIA patients within a care research framework. METHOD CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (mRS<3) at 10 years. All UIA patients at one center are reported. RESULTS Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the RCTs and 224 (56%) in one of the registries. Conservative management was recommended for 205/403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n=81) or curative treatment (n=78). These patients were younger and had larger aneurysms than those in the observation registry (P = .004). In 39/198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141/159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed-over to the alternative management option. CONCLUSION CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.
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Affiliation(s)
- Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jennifer Collins
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Behzad Farzin
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Edmonton, Alberta, Canada
| | - Johanna Eneling
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Leonardo Olijnyk
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Grégoire Boulouis
- Neuroradiology Department, Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, France
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada and CHUM Research Center (CRCHUM), Montreal, Quebec, Canada.
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9
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Darsaut TE, Keough MB, Boisseau W, Findlay JM, Bojanowski MW, Chaalala C, Iancu D, Weill A, Roy D, Estrade L, Lejeune JP, Januel AC, Carlson AP, Sauvageau E, Al-Jehani H, Orlov K, Aldea S, Piotin M, Gaberel T, Gevry G, Raymond J. Middle Cerebral Artery Aneurysm Trial (MCAAT): A randomized care trial comparing surgical and endovascular management of MCA aneurysm patients. World Neurosurg 2021; 160:e49-e54. [PMID: 34971833 DOI: 10.1016/j.wneu.2021.12.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether the best management of middle cerebral artery (MCA) aneurysm patients is surgical or endovascular remains uncertain, with little evidence to guide decision-making. A randomized care trial offering MCA aneurysm patients a 50% chance of surgical and a 50% chance of endovascular management may optimize outcomes in the presence of uncertainty. METHODS The Middle Cerebral Artery Aneurysm Trial (MCAAT) is an investigator-initiated, multi-center, parallel group, prospective, 1:1 randomized controlled clinical trial. All adult patients with MCA aneurysms, ruptured or unruptured, amenable to surgical and endovascular treatment can be included. The composite primary outcome is 'Treatment Success': i) occlusion or exclusion of the aneurysm using the allocated treatment modality; ii) no intracranial hemorrhage during follow-up; iii) no retreatment of the target aneurysm during follow-up, iv) no residual aneurysm on angiographic follow-up and v) independence (mRS <3) at 1 year. The trial tests two versions of the same hypothesis (one for ruptured and one for unruptured MCA aneurysm patients): Surgical management will lead to a 15% absolute increase in the proportion of patients reaching Treatment Success from 55% to 70% (ruptured) or from 75% to 90% (unruptured aneurysm patients) compared to endovascular treatment (any method). In this pragmatic trial, outcome evaluations are by treating physicians, except for 1 year angiographic results which will be core lab assessed. The trial will be monitored by an independent data safety monitoring committee to assure safety of participants. MCAAT is registered at clinicaltrials.gov: NCT05161377. CONCLUSION Patients with MCA aneurysms can be optimally managed within a care trial protocol.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - William Boisseau
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Canada
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU de Lille, Hôpital Salengro, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, CHU de Lille, Hôpital Salengro, Lille, France
| | - Anne-Christine Januel
- Department of Interventional Neuroradiology, CHU de Toulouse, Hôpital Purpan, Toulouse, France
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida, USA
| | - Hosam Al-Jehani
- Department of Neurosurgery and Radiology, King Fahad University Hospital, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Kirill Orlov
- Endovascular Neurosurgery Research Center, Federal Center of Brain Research and Neurotechnologies of the Federal Medical Biological Agency of Russia, Moscow, Russia
| | - Sorin Aldea
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | | | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada
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Darsaut TE, Keough MB, Sagga A, Chan VKY, Diouf A, Boisseau W, Magro E, Kotowski M, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Bilocq A, Estrade L, Lejeune JP, Bricout N, Scholtes F, Martin D, Otto B, Findlay JM, Chow MM, O'Kelly CJ, Ashforth RA, Rempel JL, Lesiuk H, Sinclair J, Altschul DJ, Arikan F, Guilbert F, Chagnon M, Farzin B, Gevry G, Raymond J. Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison. World Neurosurg 2021; 149:e521-e534. [PMID: 33556601 DOI: 10.1016/j.wneu.2021.01.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.
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Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael B Keough
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Abdelaziz Sagga
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Vivien K Y Chan
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Ange Diouf
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - William Boisseau
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Elsa Magro
- Service of Neurosurgery, CHU Cavale Blanche, InsermUMR 1101 LaTIM, Brest, France
| | - Marc Kotowski
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniela Iancu
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Michel W Bojanowski
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Service of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Bilocq
- Centre Hospitalier Régional de Trois-Rivières Service of Neurosurgery, Trois-Rivières, Quebec, Canada
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Felix Scholtes
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Didier Martin
- Department of Neurosurgery, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Bernard Otto
- Division of Medical Imaging, Department of Medical Physics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - J Max Findlay
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael M Chow
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cian J O'Kelly
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Robert A Ashforth
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Howard Lesiuk
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - John Sinclair
- Section of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David J Altschul
- Department of Neurological Surgery and Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fuat Arikan
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francois Guilbert
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montréal, Quebec, Canada
| | - Behzad Farzin
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Interventional Neuroradiology Laboratory, Research Centre, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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Darsaut T, Raymond J. Experience using pragmatic care trials to guide neurovascular practice under uncertainty. Neurochirurgie 2020; 66:423-428. [DOI: 10.1016/j.neuchi.2020.06.136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/04/2023]
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Darsaut TE, Raymond J. Practicing outcome-based medical care using pragmatic care trials. Trials 2020; 21:899. [PMID: 33121523 PMCID: PMC7599099 DOI: 10.1186/s13063-020-04829-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022] Open
Abstract
The current separation between medical research and care is an obstacle to essential aspects of good medical practice: the verification that care interventions actually deliver the good outcomes they promise, and the use of scientific methods to optimize care under uncertainty. Pragmatic care trials have been designed to address these problems. Care trials are all-inclusive randomized trials integrated into care. Every item of trial design is selected in the best medical interest of participating patients. Care trials can eventually show what constitutes good medical practice based on patient outcomes. In the meantime, care trials give clinicians and patients the scientific methods necessary for optimization of medical care when no one really knows what to do.We report the progress of 9 randomized care trials that were used to guide the endovascular or surgical management of 1212 patients with acute stroke, intracranial aneurysms, and arteriovenous malformations in a single center in an elective or acute care context. Care trials were used to address long-standing dilemmas regarding rival medical, surgical, or endovascular management options or to offer innovative instead of standard treatments. The trial methodology, by replacing unrepeatable treatment decisions by 1:1 randomized allocation whenever reliable knowledge was not available, had an immediate impact, transforming unverifiable dogmatic medical practice into verifiable outcome-based medical care. We believe the approach is applicable to all medical or surgical domains, but widespread adoption may require the revision of many currently prevalent views regarding the role of research in clinical practice.
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Affiliation(s)
- Tim E. Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, 8440 - 112 Street, Edmonton, Alberta T6G 2B7 Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l’Université de Montréal – CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC H2X 0C1 Canada
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Darsaut TE, Desal H, Cognard C, Januel AC, Bourcier R, Boulouis G, Shiva Shankar JJ, Findlay JM, Rempel JL, Fahed R, Boccardi E, Valvassori L, Magro E, Gentric JC, Bojanowski MW, Chaalala C, Iancu D, Roy D, Weill A, Diouf A, Gevry G, Chagnon M, Raymond J. Comprehensive Aneurysm Management (CAM): An All-Inclusive Care Trial for Unruptured Intracranial Aneurysms. World Neurosurg 2020; 141:e770-e777. [PMID: 32526362 DOI: 10.1016/j.wneu.2020.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain. METHODS Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age <60 years. RESULTS The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score <3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score >2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study. CONCLUSIONS Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial.
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Affiliation(s)
- Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division Crosurgery, Edmonton, Alberta, Canada
| | - Hubert Desal
- Service de Neuroradiologie Diagnostique et Interventionnelle du CHU de Nantes, Nantes, France
| | - Christophe Cognard
- Service de Neuroradiologie Diagnostique et Thérapeutique du CHU de Toulouse, Toulouse, France
| | - Anne-Christine Januel
- Service de Neuroradiologie Diagnostique et Thérapeutique du CHU de Toulouse, Toulouse, France
| | - Romain Bourcier
- Service de Neuroradiologie Diagnostique et Interventionnelle du CHU de Nantes, Nantes, France
| | - Grégoire Boulouis
- Service Imagerie Morphologique et Fonctionnelle, Hôpital Sainte-Anne, Paris, France
| | | | - J Max Findlay
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division Crosurgery, Edmonton, Alberta, Canada
| | - Jeremy L Rempel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert Fahed
- Department of Radiology, Service of Interventional Neuroradiology, University of Ottawa Hospitals, Civic Campus, Ottawa, Ontario, Canada
| | - Edoardo Boccardi
- Department of Neuroradiology, Metropolitan Hospital Niguarda, Milan, Italy
| | - Luca Valvassori
- Department of Neuroradiology, Metropolitan Hospital Niguarda, Milan, Italy
| | - Elsa Magro
- Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | | | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Daniela Iancu
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; CHUM Research Center, Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; CHUM Research Center, Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; CHUM Research Center, Montreal, Quebec, Canada
| | - Ange Diouf
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Guylaine Gevry
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; CHUM Research Center, Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, Université de Montréal, Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; CHUM Research Center, Montreal, Quebec, Canada.
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Darsaut T, Roy D, Weill A, Bojanowski M, Chaalala C, Bilocq A, Findlay J, Rempel J, Chow M, O’Kelly C, Ashforth R, Kotowski M, Magro E, Lemus M, Fahed R, Arikan F, Arrese I, Sarabia R, Altschul D, Chagnon M, Guilbert F, Shankar J, Proust F, Nolet S, Gevry G, Raymond J. A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2. Neurochirurgie 2019; 65:370-376. [DOI: 10.1016/j.neuchi.2019.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/09/2019] [Accepted: 05/30/2019] [Indexed: 01/08/2023]
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Raymond J, Januel AC, Iancu D, Roy D, Weill A, Carlson A, Darsaut TE. The RISE trial: A Randomized Trial on Intra-Saccular Endobridge devices. Interv Neuroradiol 2019; 26:61-67. [PMID: 31690151 DOI: 10.1177/1591019919886412] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Wide-necked bifurcation aneurysms (WNBA) are a difficult subset of aneurysms to successfully repair endovascularly, and a number of treatment adjuncts have been designed to improve on the results of coiling, including stenting and flow diversion of the parent vessel. Surgical clipping is commonly performed for certain WNBAs, such as middle cerebral aneurysms, in some centres. Intra-saccular flow diversion (ISFD) using the Woven Endo-Bridge (WEB) or similar devices, has been developed as a new endovascular alternative to coiling for WNBAs. Meta-analyses of case series suggest satisfactory results, both in terms of safety and efficacy, but in the absence of randomized evidence, whether ISFD leads to better outcomes for patients with WNBA remains unknown. There is a need to offer ISFD within the context of a randomized care trial. METHODS The proposed trial is a multicentre, randomized controlled care trial comparing ISFD and best conventional management option (surgical or endovascular), as determined by the treating physician prior to randomized allocation. At least 250 patients will be recruited in at least 10 centres over a four-year period, and followed for one year, to show that ISFD can increase the incidence of successful therapy from 75 to 90% of patients, defined as complete or near-complete occlusion of the aneurysm AND a good clinical outcome (mRS ≤ 2) at one year. The trial will be followed by an independent data safety monitoring committee to assure the safety of participants. CONCLUSION Introduction of intra-saccular flow diversion can be accomplished within a care trial context.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Anne-Christine Januel
- Department of Neuroradiology, Service de Neuroradiologie Diagnostique et Thérapeutique du CHU de Toulouse, University Hospital of Toulouse, Toulouse, France
| | - Daniela Iancu
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Andrew Carlson
- Department of Neurological Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta hospital, Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
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Kallmes DF, Brinjikji W, Rabinstein AA. Letter to the Editor. Flow Diversion in the Treatment of Intracranial Aneurysm Trial. J Neurosurg 2017; 127:703-707. [DOI: 10.3171/2016.12.jns163176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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