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Hao Q, Zhang H, Han H, Jin H, Ma L, Li R, Li Z, Li A, Yuan K, Zhu Q, Wang K, Li R, Lin F, Wang C, Zhang Y, Zhang H, Zhao Y, Jin W, Gao D, Guo G, Yan D, Pu J, Kang S, Ye X, Li Y, Sun S, Wang H, Chen Y, Chen X, Zhao Y. Recurrence of Cerebral Arteriovenous Malformation Following Complete Obliteration Through Endovascular Embolization. Transl Stroke Res 2023:10.1007/s12975-023-01215-8. [PMID: 37957446 DOI: 10.1007/s12975-023-01215-8] [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: 10/17/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Arteriovenous malformation (AVM) recurrence after embolization was rarely reported. This study aimed to explore the potential risk factors of recurrence in angiographically obliterated AVMs treated with endovascular embolization. This study reviewed AVMs treated with embolization only in a prospective multicenter registry from August 2011 to December 2021, and ultimately included 92 AVMs who had achieved angiographic obliteration. Recurrence was assessed by follow-up digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). Hazard ratios (HRs) with 95% confidence intervals were calculated using Cox proportional hazards regression models. Nineteen AVMs exhibited recurrence on follow-up imaging. The recurrence rates after complete obliteration at 6 months, 1 year, and 2 years were 4.35%, 9.78%, and 13.0%, respectively. Multivariate Cox regression analysis identified diffuse nidus (HR 3.208, 95% CI 1.030-9.997, p=0.044) as an independent risk factor for recurrence. Kaplan-Meier analysis confirmed a higher cumulative risk of recurrence with diffuse nidus (log-rank, p=0.016). Further, in the exploratory analysis of the effect of embolization timing after AVM rupture on recurrence after the complete obliteration, embolization within 7 days of the hemorrhage was found as an independent risk factor (HR 4.797, 95% CI 1.379-16.689, p=0.014). Kaplan-Meier analysis confirmed that embolization within 7 days of the hemorrhage was associated with a higher cumulative risk of recurrence in ruptured AVMs (log-rank, p<0.0001). This study highlights the significance of diffuse nidus as an independent risk factor for recurrence after complete embolization of AVMs. In addition, we identified a potential recurrent risk associated with early embolization in ruptured AVMs.
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Affiliation(s)
- Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qinghui Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengzhuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yukun Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Hongwei Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yang Zhao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Weitao Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Geng Guo
- Department of Emergency, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Xi'an, Shanxi, China
| | - Jun Pu
- Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Ghatge S, Itti P. Curative Embolization of Small Brain Arteriovenous Malformations by Ethyl Vinyl Alcohol Copolymer: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27219. [PMID: 36035052 PMCID: PMC9399823 DOI: 10.7759/cureus.27219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
The right choice in treating small (Spetzler-Ponce grade A) brain arteriovenous malformations (AVMs) is a matter of debate with varying views from neurology, neurosurgery, and interventional neuroradiology points of view. The Spetzler-Martin 1 and 2 brain AVMs, especially those in eloquent and deep areas that are difficult to access by micro-neurosurgery, are most suitable for a complete cure by endovascular embolization with ethyl vinyl alcohol (EVOH)-based agents. A literature search was done with keywords such as endovascular embolization of small brain AVM. Data from 13 articles are included in the study based on predetermined inclusion and exclusion criteria. Meta-analysis for the complete cure rate was done, publication bias was removed, and regression analysis showed a 76% cure rate with a 95% confidence interval (CI). Major complications were hemorrhage and neurological deficit, which ranged from 0-20% and 0-16% with a mean proportion of 0.11 and 0.09, respectively. Long-term (3-6 months) follow-up data showed 0-4% recurrence at three months, 0-8% recurrence at six months, and 2-10% permanent disability. The mortality rate ranged from 3% to 4%. Three illustrative cases with data from the author’s institute are included in the article. To conclude, endovascular embolization for small brain AVMs is a satisfactory treatment modality, however, prospective registries and randomized controlled trials involving embolization versus neurosurgery and/or stereotactic radiosurgery (SRS) may validate the role of embolization in small brain AVMs as curative treatment.
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Ahmetspahic A, Burazerovic E, Hajdarpasic E, Dzurlic A, Omerhodzic I, Sefo H, Kato Y. Multimodality Management in bAVM Surgery - Recent Experience from International Cerebrovascular Fellowship. Med Arch 2021; 75:209-215. [PMID: 34483452 PMCID: PMC8385728 DOI: 10.5455/medarh.2021.75.209-215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Arteriovenous malformation (bAVM) presents maldevelopment of the brain’s vessels with a direct connection between cerebral arteries and veins. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable. Objective: Arteriovenous malformation presents maldevelopment of the brain’s vessels with a consequent direct connection between cerebral arteries and veins. The annual risk of hemorrhage in adults is reported for 2-3 %. They usually present with unilateral headaches seizures and intracranial hemorrhage. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable. Methods: The study included a cohort of bAVM patients referred to Fujita Health University Bantane Hotokukai Hospital, Nagoya, Aichi, Japan where the main author (AA) has completed an international cerebrovascular fellowship under the mentorship of Professor Yoko Kato. Japanese Stroke Guidelines (JSG) were used for the treatment decision. Patients were graded according to the Spetzler Ponce (SP) system. Considering American Heart Association criteria (AHA), embolization was used as a part of multimodal treatment. Intraoperative microscopic video tools included Indocyanine green ICG, FLOW 800 and dual image video angiography DIVA. Clinical outcomes were measured using Modified Ranking Score (mRs). Results: A total of eleven patients with brain bAVM were studied with a median age of 32 years [IQR = 22-52]. There were ten patients presented with supratentorial and a single patient with infratentorial AVM. Patients were graded according to the Spetzler Ponce (SP) system. There were eight patients in SP A (72,7%), one in group B (9 %) while the rest of them were in C (18 %). Two patients had associated aneurysms that required treatment. The median size of the AVM nidus was 3,50 cm [IQR= 2-5]. Deep venous drainage was found in six patients while three were located in eloquent zones. Clinical outcomes were considered good by mRs <2 in eight patients, seven from the surgically treated group (72,7 % respectively). Surgery median length time was 427, 5 minutes; [IQR =320 - 463] with complete AVM resection in all patients and no mortality recorded in this cohort with the median follow up of 39,5 months [IQR = 19-59]. Conclusion: Ideal management of bAVM is still controversial. Those complex vascular lesions require multimodal treatment in a majority of cases in highly specialized centers. In SP A patients, surgery provides the best results with a positive outcome and a small number of complications. With the improvement of endovascular feeder occlusion SP B patients become prone to a more positive outcome. Nowadays, intraoperative microscopic tools such as FLOW 800, ICG and DIVA are irreplaceable while improving safety to deal with bAVM. For SP C patients, a combination of endovascular and stereotactic radiosurgery was found to be a good option in the present time.
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Affiliation(s)
- Adi Ahmetspahic
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina.,Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina
| | - Eldin Burazerovic
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina
| | - Edin Hajdarpasic
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina
| | - Almir Dzurlic
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina.,Sarajevo School of Science and Technology (SSST), Sarajevo, Bosnia and Herzegovina
| | - Ibrahim Omerhodzic
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina
| | - Haso Sefo
- Clinical Center of University in Sarajevo (CCUS), Sarajevo, Bosnia and Herzegovina
| | - Yoko Kato
- Fujita Health University Center, Bantane Hotokukai Hospital, Nagoya, Aichi, Japan
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Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study. Acta Neurochir (Wien) 2021; 163:2489-2495. [PMID: 34287695 DOI: 10.1007/s00701-021-04936-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. METHODS The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. RESULTS A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). CONCLUSION The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.
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Eisenmenger LB, Junn JC, Cooke D, Hetts S, Zhu C, Johnson KM, Manunga JM, Saloner D, Hess C, Kim H. Presence of Vessel Wall Hyperintensity in Unruptured Arteriovenous Malformations on Vessel Wall Magnetic Resonance Imaging: Pilot Study of AVM Vessel Wall "Enhancement". Front Neurosci 2021; 15:697432. [PMID: 34366779 PMCID: PMC8334001 DOI: 10.3389/fnins.2021.697432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/28/2021] [Indexed: 01/06/2023] Open
Abstract
Purpose: High-resolution vessel wall magnetic resonance imaging (VW-MRI) could provide a way to identify high risk arteriovenous malformation (AVM) features. We present the first pilot study of clinically unruptured AVMs evaluated by high-resolution VW-MRI. Methods: A retrospective review of clinically unruptured AVMs with VW-MRI between January 1, 2016 and December 31, 2018 was performed documenting the presence or absence of vessel wall “hyperintensity,” or enhancement, within the nidus as well as perivascular enhancement and evidence of old hemorrhage (EOOH). The extent of nidal vessel wall “hyperintensity” was approximated into five groups: 0, 1–25, 26–50, 51–75, and 76–100%. Results: Of the nine cases, eight demonstrated at least some degree of vessel wall nidus “hyperintensity.” Of those eight cases, four demonstrated greater than 50% of the nidus with hyperintensity at the vessel wall, and three cases had perivascular enhancement adjacent to nidal vessels. Although none of the subjects had prior clinical hemorrhage/AVM rupture, of the six patients with available susceptibility weighted imaging to assess for remote hemorrhage, only two had subtle siderosis to suggest prior sub-clinical bleeds. Conclusion: Vessel wall “enhancement” occurs in AVMs with no prior clinical rupture. Additional studies are needed to further investigate the implication of these findings.
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Affiliation(s)
- Laura B Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | - Jacqueline C Junn
- Department of Radiology, Mount Sinai Hospital, New York, NY, United States
| | - Daniel Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Steven Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Kevin M Johnson
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, United States
| | - Jesse M Manunga
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, United States
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher Hess
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Helen Kim
- Department of Anesthesia, University of California, San Francisco, San Francisco, CA, United States
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Goyal M, Ospel JM, Kashani N, Siddiqui AH, Hanel R, Almekhlafi M, Chapot R. What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment. Neuroradiology 2021; 62:411-416. [PMID: 31974635 DOI: 10.1007/s00234-020-02365-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA. .,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA.
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, USA
| | - Ricardo Hanel
- Baptist Neurological Institute, Baptist Health System, Jacksonville, USA
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - René Chapot
- Department of Interventional Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany
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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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8
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Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2020; 215:472-487. [DOI: 10.2214/ajr.19.22443] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Byun J, Kwon DH, Lee DH, Park W, Park JC, Ahn JS. Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM. J Korean Neurosurg Soc 2020; 63:415-426. [PMID: 32423182 PMCID: PMC7365281 DOI: 10.3340/jkns.2020.0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/29/2020] [Indexed: 11/27/2022] Open
Abstract
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.
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Affiliation(s)
- Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Feghali J, Huang J. Updates in arteriovenous malformation management: the post-ARUBA era. Stroke Vasc Neurol 2019; 5:34-39. [PMID: 32411406 PMCID: PMC7213498 DOI: 10.1136/svn-2019-000248] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/31/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are complex and heterogeneous lesions that can rupture, causing significant morbidity and mortality. While ruptured lesions are usually treated, the management of unruptured AVMs remains unclear. A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was the first trial conducted to compare the effects of medical and interventional therapy. Although it concluded that medical therapy was superior in preventing stroke and death over a follow-up period of 33 months, the findings were met with intense criticism regarding several aspects of study design, progression, and analysis/conclusion. Namely, the increased use of stand-alone embolisation relative to microsurgery in a cohort with predominantly low-grade lesions combined with a short follow-up period amplified treatment risk. Subsequently, several observational studies were conducted on ARUBA-eligible patients to investigate the safety and efficacy of microsurgery, radiosurgery, and endovascular embolisation over longer follow-up periods. These reports showed that favourable safety profiles and cure rates can be achieved with appropriate patient selection and judicious use of different treatment modalities in multidisciplinary centres. Since large prospective randomised trials on AVMs may not be feasible, it is important to make use of practice-based data beyond the flawed ARUBA study to optimise patients' lifetime outcomes.
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Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Jhaveri A, Amirabadi A, Dirks P, Kulkarni AV, Shroff MM, Shkumat N, Krings T, Pereira VM, Rea V, Muthusami P. Predictive Value of MRI in Diagnosing Brain AVM Recurrence after Angiographically Documented Exclusion in Children. AJNR Am J Neuroradiol 2019; 40:1227-1235. [PMID: 31248861 DOI: 10.3174/ajnr.a6093] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE MRI is routinely performed following brain AVM after treatment in children. Our aim was to determine the predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence in children, compared with conventional angiography and the role of 3D rotational angiography-MR imaging fusion in these cases. MATERIALS AND METHODS We included all pediatric patients with brain AVMs during an 18-year period with angiographically documented obliteration after treatment. Patients underwent 3T MR imaging, including contrast-enhanced MR imaging, TOF-MRA, and conventional angiography, with a subset undergoing 3D rotational angiography. The predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence were determined. CTA sections reconstructed from 3D rotational angiography were coregistered with and fused to 3D-T1WI for analysis. RESULTS Thirty-nine children (10.8 ± 3.9 years of age; range, 2-17 years; male/female ratio, 19:20; mean Spetzler-Martin grade, 1.9 ± 0.6) met the inclusion criteria. Of these, 13 had angiographically confirmed brain AVM recurrence, 8 following surgery and 5 following embolization. Sensitivity, specificity, and positive and negative predictive values for recurrence were the following: contrast-enhanced MR imaging: 84.6%, 38.5%, 40.7%, 81.8%; TOF-MRA: 50.0%, 96.1%, 85.7%, 79.3%; both: 75.0%, 90.9%, 85.7%, 83.3%. 3D rotational angiography-MR imaging fused images confirmed or excluded recurrence in all available cases (13/13). Embolization-only treatment was a significant predictor of recurrence (OR = 32.4, P = .006). MR imaging features predictive of recurrence included a tuft of vessels on TOF-MRA and nodular juxtamural/linear enhancement with a draining vein on contrast-enhanced MR imaging. CONCLUSIONS MR imaging is useful for surveillance after brain AVM treatment in children, but conventional angiography is required for definitive diagnosis of recurrence. TOF-MRA and contrast-enhanced MR imaging provide complementary information for determining brain AVM recurrence and should be interpreted in conjunction. 3D rotational angiography-MR imaging fusion increases the diagnostic confidence regarding brain AVM recurrence and is therefore suited for intraoperative neuronavigation.
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Affiliation(s)
- A Jhaveri
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - A Amirabadi
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Dirks
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - A V Kulkarni
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M M Shroff
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - N Shkumat
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - T Krings
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V Rea
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Muthusami
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
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Joyce C, Gomez CR. Reimagining ARUBA: Theoretical Optimization of the Treatment of Unruptured Brain Arteriovenous Malformations. J Stroke Cerebrovasc Dis 2018; 27:3100-3107. [PMID: 30093202 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND AND PURPOSE The results of the A Randomized Trial of Unruptured Brain Arteriovenous (ARUBA) study, indicating that conservative medical management of unruptured brain arteriovenous malformations (UBAVM) is superior to interventional therapy, have generated debates that have hampered their application into clinical practice. Irrespectively of study conclusions, it seems reasonable to explore how much better interventional therapy would have to be to become competitive with conservative medical management. METHODS We conducted an exploratory analysis to replicate the original data from ARUBA. The functional form of the replicated ARUBA data, according to their Weibull distribution, allowed estimation of parameters. We carried out Monte Carlo simulations while introducing theoretical reductions of interventional risk, and the results were used to construct theoretical and example Kaplan-Meier curves from simulations. RESULTS The "ARUBA Replication" analysis showed results nearly identical to those published in the study, with an estimated hazard ratio of 0.27 (95% CI: 0.14-0.55). At 50% interventional risk reduction, the simulations showed an estimated event rate of 14.9%, and the protective effect of conservative medical management was no longer statistically significant. Greater risk reductions hastened the time to benefit for interventional therapy, and an 80% risk reduction demonstrated superiority of interventional therapy at just over 2 years Hazard Ratio (HR: 1.44, 95% CI: 0.55-4.92). CONCLUSIONS Reduction in risk of interventional therapy by 50%-80% results in more competitive clinical outcomes, equating or surpassing the benefit of conservative medical management of UBAVM. This conjecture should be taken into consideration in the design of future studies of this patient population, particularly because it is supported by recent observational studies.
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Affiliation(s)
- Cara Joyce
- Department of Public Health Sciences, Loyola University Chicago. Stritch School of Medicine. Maywood, IL
| | - Camilo R Gomez
- Department of Neurology, Loyola University Chicago. Stritch School of Medicine. Maywood, IL; Neuroendovascular Surgery Program, Loyola University Medical Center, Maywood, IL.
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Lang M, Moore NZ, Rasmussen PA, Bain MD. Treatment Outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformation-Eligible Unruptured Brain Arteriovenous Malformation Patients. Neurosurgery 2017; 83:548-555. [DOI: 10.1093/neuros/nyx506] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/18/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization.
OBJECTIVE
To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution.
METHODS
Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death.
RESULTS
A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively.
CONCLUSION
We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.
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Affiliation(s)
- Min Lang
- Case Western Reserve University, School of Medicine, Cleveland, Ohio
- Cerebrovascular Center, Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Nina Z Moore
- Cerebrovascular Center, Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Peter A Rasmussen
- Cerebrovascular Center, Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Mark D Bain
- Cerebrovascular Center, Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
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