IMPACT OF ARUBA TRIAL ON CURRENT PRACTICE: INTERVENTIONAL TREATMENT AND STROKE RATES IN UNRUPTURED BRAIN ARTERIOVENOUS MALFORMATIONS IN THE POST-ARUBA ERA
Brain AVMs are the abnormal connection between veins and arteries of the brain, that can lead to headaches, seizures, and hemorrhages. The choice of treatment for bAVMs depends on several factors, such as the size and location of the malformations, the severity of symptoms, and the risk of hemorrhage. The ARUBA was a clinical trial that aimed to determine the best treatment approach for unruptured AVMs. Its results showed that conservative management was associated with a significantly lower risk of death or stroke compared to intervention, leading to a shift in the practice of neurosurgeons. In this review, trends in the post-ARUBA rates of stroke and interventions for unruptured bAVMs are discussed.
A noticeable decrease in the number of interventions for unruptured bAVMs has been seen post-ARUBA. This reduction has been particularly evident in minimally invasive procedures such as endovascular embolization and stereotactic radiosurgery. However, microsurgery, which is considered the gold standard for small-sized bAVMs, has remained consistent in terms of the number of procedures performed for ARUBA-eligible patients.
Chingiz S. Nurimanov1, https://orcid.org/0000-0002-8251-7980
Karashash K. Menlibayeva1, https://orcid.org/0000-0002-3021-6350
Yerbol T. Makhambetov1, https://orcid.org/0000-0003-1180-4285
Elena V. Zholdybayeva2, https://orcid.org/0000-0002-9677-008X
1 National Centre for Neurosurgery, Astana, Republic of Kazakhstan;
2 National Center for Biotechnology, Astana, Republic of Kazakhstan.
1. Abecassis I.J., Xu D.S., Batjer H.H., Bendok B.R. Natural history of brain arteriovenous malformations: a systematic review // Neurosurg Focus 2014. 37:E7. doi: 10.3171/2014.6.FOCUS14250
2. Alrohimi A., Achey R.L., Thompson N., Abdalla R.N., Patterson T., Moazeni Y., Rasmussen P.A., Toth G., Bain M.D., Ansari S.A., Hussain S.M., Moore N.Z. Treatment outcomes for ARUBA-eligible brain arteriovenous malformations: a comparison of real-world data from the NVQI-QOD AVM registry with the ARUBA trial // Journal of NeuroInterventional Surgery. 2024. doi: 10.1136/jnis-2023-020525
3. Al-Yamany M., terBrugge K.G., Willinsky R., Montanera W., Tymianski M., Wallace M.C. alliative Embolisation of Brain Arteriovenous Malformations Presenting with Progressive Neurological Deficit // Interv Neuroradiol. 2000. P 6:177–183. doi: 10.1177/159101990000600302
4. Am L., Cd C.-L., Ma A.-S., Ku F., Wb G., Ra M., Nj P. Seizure Outcomes After Interventional Treatment in Cerebral Arteriovenous Malformation-Associated Epilepsy: A Systematic Review and Meta-Analysis // World neurosurgery, 2022.160. doi: 10.1016/j.wneu.2021.09.063
5. Baharvahdat H., Blanc R., Fahed R., Smajda S., Ciccio G., Desilles J.-P., Redjem H., Escalard S., Mazighi M., Chauvet D., Robert T., Sasannejad P., Piotin M. Endovascular Treatment for Low-Grade (Spetzler-Martin I-II) Brain Arteriovenous Malformations // AJNR Am J Neuroradiol. 2019.40:668–672. doi: 10.3174/ajnr.A5988
6. van Beijnum J., van der Worp H.B., Buis D.R., Al-Shahi Salman R., Kappelle L.J., Rinkel G.J.E., van der Sprenkel J.W.B., Vandertop W.P., Algra A, Klijn C.J.M. Treatment of brain arteriovenous malformations: a systematic review and meta-analysis // JAMA 2011. 306:2011–2019. doi: 10.1001/jama.2011.1632
7. Birnbaum L.A., Straight M., Hegde S., Lacci J.V., de Leonni Stanonik M., Mascitelli J.R., McDougall C.M., Caron J.-L.R. Microsurgery for Unruptured Cerebral Arteriovenous Malformations in the National Inpatient Sample is More Common Post-ARUBA // World Neurosurg. 2020.137:e343–e346. doi: 10.1016/j.wneu.2020.01.211
8. Bokhari M.R., Bokhari S.R.A. Arteriovenous Malformation of the Brain. In: StatPearls. StatPearls Publishing, Treasure Island (FL). 2024. 256 p.
9. Cenzato M., Delitala A., Delfini R., Pasqualin A., Maira G., Esposito V., Tomasello F., Boccardi E. Position statement from the Italian Society of Neurosurgery on the ARUBA Study // J Neurosurg Sci. 201660:126–130
10. Chen Y., Han H., Jin H., Meng X., Ma L., Li R., Li Z., Yan D., Zhang H., Yuan K., Wang K., Zhao Y., Zhang Y., Jin W., Li R., Lin F., Hao Q., Wang H., Ye X., Kang S., Gao D., Pu J., Shi Z., Chao X., Lin Z., Lu J., Li J., Sun S., Liu A., Chen X., Li Y., Zhao Y., Wang S. Registry of Multimodality Treatment for Brain Arteriovenous Malformation in Mainland China (MATCH). Association of embolization with long-term outcomes in brain arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data // Int J Surg. 2023. 109:1900–1909. doi: 10.1097/JS9.0000000000000341
11. Davidson A.S., Morgan M.K. How safe is arteriovenous malformation surgery? A prospective, observational study of surgery as first-line treatment for brain arteriovenous malformations // Neurosurgery 2010. 66:498–504; discussion 504-505. doi: 10.1227/01.NEU.0000365518.47684.98
12. De Leacy R., Ansari S.A., Schirmer C.M., Cooke D.L., Prestigiacomo C.J., Bulsara K.R., Hetts S.W. S.N.I.S. Standards and Guidelines Committee, SNIS Board of Directors. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee // J Neurointerv Surg 2022. 14:1118–1124. doi: 10.1136/neurintsurg-2021-018632
13. Dicpinigaitis A.J., Ogulnick J.V., Mayer S.A., Gandhi C.D., Al‐Mufti F. Increase in Ruptured Cerebral Arteriovenous Malformations and Mortality in the United States: Unintended Consequences of the ARUBA Trial? Stroke: Vascular and Interventional Neurology. 2023. 3:e000442. doi: 10.1161/SVIN.122.000442
14. Ding D., Chen C.-J., Starke R.M., Kano H., Lee J.Y.K., Mathieu D., Feliciano C., Rodriguez-Mercado R., Almodovar L., Grills I.S., Kondziolka D., Barnett G.H., Lunsford L.D., Sheehan J.P. Risk of Brain Arteriovenous Malformation Hemorrhage Before and After Stereotactic Radiosurgery. Stroke. 2019. 50:1384–1391. doi: 10.1161/STROKEAHA.118.024230
15. Elhammady M.S., Heros R.C. Management of incidental cerebral AVMs in the post-ARUBA era // J Neurosurg. 2014. 121:1011–1014. doi: 10.3171/2014.3.JNS14135
16. Gross B.A., Du R. Natural history of cerebral arteriovenous malformations: a meta-analysis // J Neurosurg. 2013. 118:437–443. doi: 10.3171/2012.10.JNS121280
17. Han H., Chen Y., Ma L., Li R., Li Z., Zhang H., Yuan K., Wang K., Jin H., Meng X., Yan D., Zhao Y., Zhang Y., Jin W., Li R., Lin F., Hao Q., Wang H., Ye X., Kang S., Gao D., Sun S., Liu A., Li Y., Chen X., Zhao Y., Wang S. Comparison of conservative management, microsurgery only, and microsurgery with preoperative embolization for unruptured arteriovenous malformations: A propensity score weighted prospective cohort study // CNS Neuroscience & Therapeutics. 2024. 30:e14533. doi: 10.1111/cns.14533
18. Han H., Gao D., Ma L., Li R., Li Z., Zhang H., Yuan K., Wang K., Zhang Y., Zhao Y., Jin W., Jin H., Meng X., Yan D., Li R., Lin F., Hao Q., Wang H., Ye X., Kang S., Pu J., Shi Z., Chao X., Lin Z., Lu J., Li Y., Zhao Y., Sun S., Chen Y., Chen X., Wang S. Registry of Multimodality Treatment for Brain Arteriovenous Malformation in Mainland China (MATCH) (2023) Long-term outcomes of microsurgery and stereotactic radiosurgery as the first-line treatment for arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data // Int J Surg 109:3983–3992. doi: 10.1097/JS9.0000000000000751
19. Hasegawa T., Kato T., Naito T., Tanei T., Okada K., Ito R., Koketsu Y., Hirayama K. Long-Term Risks of Hemorrhage and Adverse Radiation Effects of Stereotactic Radiosurgery for Brain Arteriovenous Malformations. Neurosurgery. 2022. 90:784–792. doi: 10.1227/neu.0000000000001913
20. Ikedo T., Yamamoto E.H., Mori H., Niwa A., Ozaki S., Kushi Y., Shimonaga K., Hamano E., Yamada K., Imamura H., Iihara K., Kataoka H. Impact of tailored multimodal treatment for unruptured brain arteriovenous malformation: comparison with a randomized trial of unruptured brain arteriovenous malformations // Acta Neurochir (Wien) 2023. 165:3779–3785. doi: 10.1007/s00701-023-05815-z
21. Ilyas A., Chen C.-J., Ding D., Buell T.J., Raper D.M.S., Lee C.-C., Xu Z., Sheehan J.P. Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis // Neurosurgery. 2018. 83:365–376. doi: 10.1093/neuros/nyx502
22. Javadpour M., Al-Mahfoudh R., Mitchell P.S., Kirollos R. Outcome of microsurgical excision of unruptured brain arteriovenous malformations in ARUBA-eligible patients // Br J Neurosurg. 2016.30:619–622. doi: 10.1080/02688697.2016.1181153
23. Karlsson B., Jokura H., Yang H.-C., Yamamoto M., Martinez R., Kawagishi J., Guo W.-Y., Beute G., Pan D.H.C., Aiyama H., Chung W.-Y., Söderman M., Yeo T.T. The NASSAU (New ASSessment of cerebral Arteriovenous Malformations yet Unruptured) Analysis: Are the Results From The ARUBA Trial Also Applicable to Unruptured Arteriovenous Malformations Deemed Suitable for Gamma Knife Surgery? // Neurosurgery. 2019. 85:E118. doi: 10.1093/neuros/nyy391
24. Kato Y., Dong V.H., Chaddad F., Takizawa K., Izumo T., Fukuda H., Hara T., Kikuta K., Nakai Y., Endo T., Kurita H., Xu B., Beneš V., Christian R., Pavesi G., Hodaie M., Sharma R.K., Agarwal H., Mohan K., Liew B.S. Expert Consensus on the Management of Brain Arteriovenous Malformations // Asian J Neurosurg. 2019. 14:1074–1081. doi: 10.4103/ajns.AJNS_234_19
25. Khaliq A., Khizar A., Hassan R.M., Khan M.I., Gul N. Outcomes of Microsurgical Resection of Low-Grade Cerebral Arteriovenous Malformations: A Prospective Observational Multicenter Study from a Low-Middle-Income Country // Brain Hemorrhages. 2024. 5:14–20. doi: 10.1016/j.hest.2023.06.002
26. Krings T., Hans F.-J., Geibprasert S., Terbrugge K. Partial “targeted” embolisation of brain arteriovenous malformations // Eur Radiol 2010. 20:2723–2731. doi: 10.1007/s00330-010-1834-3
27. Lang M., Moore N.Z., Rasmussen P.A., Bain M.D. Treatment Outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformation-Eligible Unruptured Brain Arteriovenous Malformation Patients // Neurosurgery. 2018. 83:548–555. doi: 10.1093/neuros/nyx506
28. Lawton M.T., Kim H., McCulloch C.E., Mikhak B., Young W.L. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery // Neurosurgery. 2010. 66:702–713; discussion 713. doi: 10.1227/01.NEU.0000367555.16733.E1
29. Leksell L. The stereotaxic method and radiosurgery of the brain // Acta Chir Scand. 1951. 102:316–319
30. Link T.W., Winston G., Schwarz J.T., Lin N., Patsalides A., Gobin P., Pannullo S., Stieg P.E., Knopman J. Treatment of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience of 86 Patients and a Critique of the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) Trial. // World Neurosurg. 2018 120:e1156–e1162. doi: 10.1016/j.wneu.2018.09.025
31. Luther E., McCarthy D.J., Burks J., Govindarajan V., Lu V.M., Silva M., Lang M., Gross B.A., Starke R.M. National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence // Journal of NeuroInterventional Surgery. 2023.15:735–740. doi: 10.1136/jnis-2022-019110
32. Maalim A.A., Zhu M., Shu K., Wu Y., Zhang S., Ye F., Zeng Y., Huang Y., Lei T. Microsurgical Treatment of Arteriovenous Malformations: A Single-Center Study Experience. Brain Sci. 2023. 13:1183. doi: 10.3390/brainsci13081183
33. Magro E., Gentric J.-C., Darsaut T.E., Ziegler D., Bojanowski M.W., Raymond J. Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials // J Neurosurg. 2017. 126:486–494. doi: 10.3171/2015.6.JNS15619
34. Mohr J.P., Overbey J.R., Hartmann A., Kummer R. von, Al-Shahi S.alman R., Kim H., van der Worp H.B., Parides M.K., Stefani M.A., Houdart E., Libman R., Pile-Spellman J., Harkness K., Cordonnier C., Moquete E., Biondi A., Klijn C.J.M., Stapf C., Moskowitz A.J. ARUBA co-investigators (2020) Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial // Lancet Neurol 19:573–581. doi: 10.1016/S1474-4422(20)30181-2
35. Mohr J.P., Parides M.K., Stapf C., Moquete E., Moy C.S., Overbey J.R., Al-Shahi Salman R., Vicaut E., Young W.L., Houdart E., Cordonnier C., Stefani M.A., Hartmann A., von Kummer R., Biondi A., Berkefeld J., Klijn C.J.M., Harkness K., Libman R., Barreau X., Moskowitz A.J. international ARUBA investigators Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial // Lancet. 2014. 383:614–621. doi: 10.1016/S0140-6736(13)62302-8
36. Mosimann P.J., Chapot R. Contemporary endovascular techniques for the curative treatment of cerebral arteriovenous malformations and review of neurointerventional outcomes // J Neurosurg Sci 2018. 62:505–513. doi: 10.23736/S0390-5616.18.04421-1
37. Nerva J.D., Mantovani A., Barber J., Kim L.J., Rockhill J.K., Hallam D.K., Ghodke B.V., Sekhar L.N. Treatment outcomes of unruptured arteriovenous malformations with a subgroup analysis of ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-eligible patients // Neurosurgery 2015. 76:563–570; discussion570; quiz 570. doi: 10.1227/NEU.0000000000000663
38. Patel S.D., Saber H., Desai N., Otite F.O., Kaneko N., Mehta T.V., Hinman J., Hassan A.E., Jadhav A., Liebeskind D.S., Saver J.L. Impact of ARUBA trial on trends and outcomes in symptomatic non-ruptured brain AVMs: A national sample analysis // Journal of Stroke and Cerebrovascular Diseases. 2022. 31. doi: 10.1016/j.jstrokecerebrovasdis.2022.106807
39. Pollock B.E., Link M.J., Brown R.D. The risk of stroke or clinical impairment after stereotactic radiosurgery for ARUBA-eligible patients // Stroke. 2013. 44:437–441. doi: 10.1161/STROKEAHA.112.670232
40. Pulli B., Chapman P.H., Ogilvy C.S., Patel A.B., Stapleton C.J., Leslie-Mazwi T.M., Hirsch J.A., Carter B.S., Rabinov J.D. Multimodal cerebral arteriovenous malformation treatment: a 12-year experience and comparison of key outcomes to ARUBA // J Neurosurg 2019. 1–10. doi: 10.3171/2019.8.JNS19998
41. Rf S., Na M. A proposed grading system for arteriovenous malformations // Journal of neurosurgery 1986. 65. doi: 10.3171/jns.1986.65.4.0476
42. Starke R.M., Kano H., Ding D., Lee J.Y.K., Mathieu D., Whitesell J., Pierce J.T., Huang P.P., Kondziolka D., Yen C.-.P, Feliciano C., Rodgriguez-Mercado R., Almodovar L., Pieper D.R., Grills I.S., Silva D., Abbassy M., Missios S., Barnett G.H., Lunsford L.D., Sheehan J.P. Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort // J Neurosurg. 2017. 126:36–44. doi: 10.3171/2015.9.JNS151311
43. Sussman E.S., Iyer A.K., Teo M., Pendharkar A.V., Ho A.L., Steinberg G.K. Interventional therapy for brain arteriovenous malformations before and after ARUBA // J Clin Neurosci. 2017. 37:54–56. doi: 10.1016/j.jocn.2016.10.036
44. Teo M., St. George J., Lawton M.T. Time for BARBADOS after ARUBA trial // British Journal of Neurosurgery. 2015 29:635–636. doi: 10.3109/02688697.2015.1096909
45. Unnithan A. Overview of the current concepts in the management of arteriovenous malformations of the brain // Postgrad Med J. 2020. 96:212–220. doi: 10.1136/postgradmedj-2019-137202
46. Volovici V., Meling T.R. The impact of ARUBA on the clinical practice of unruptured brain arteriovenous malformations: big data, poor evidence and measuring impact on health policy // Acta Neurochir (Wien) 2021. 163:2487–2488. doi: 10.1007/s00701-021-04937-6
47. Volovici V., Schouten J.W., Vajkoczy P., Dammers R., Meling T.R. Unruptured Arteriovenous Malformations // Stroke 2021. 52:1143–1146. doi: 10.1161/STROKEAHA.120.032429
48. Wahood W., Alexander A.Y., Doherty R.J., Bhandarkar A., Lanzino G., Bydon M., Brinjikji W. Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study // Acta Neurochir (Wien). 2021. 163:2489–2495. doi: 10.1007/s00701-021-04936-7
49. Wong J., Slomovic A., Ibrahim G., Radovanovic I., Tymianski M. Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)-Eligible Unruptured Brain Arteriovenous Malformations // Stroke. 2017. 48:136–144. doi: 10.1161/STROKEAHA.116.014660
50. Yen C.-P., Matsumoto J.A., Wintermark M., Schwyzer L., Evans A.J., Jensen M.E., Shaffrey M.E., Sheehan J.P. Radiation-induced imaging changes following Gamma Knife surgery for cerebral arteriovenous malformations // J Neurosurg. 2013.118:63–73. doi: 10.3171/2012.10.JNS12402
51. Zhang Y., Chen Y., Han H., Ma L., Li R., Li Z., Yan D., Zhang H., Yuan K., Wang K., Zhao Y., Jin W., Jin H., Meng X., Li R., Lin F., Hao Q., Wang H., Ye X., Kang S., Gao D., Sun S., Liu A., Li Y., Chen X., Wang S., Zhao Y. Timing of microsurgical resection for ruptured brain arteriovenous malformations: a propensity score-matched analysis using prospective single-center registry data // J Neurosurg. 2024. 140:164–171. doi: 10.3171/2023.5.JNS222666
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Nurimanov Ch.S., Menlibayeva K.K., Makhambetov Ye.T., Zholdybayeva E.V. Impact of ARUBA Trial on Current Practice: Interventional Treatment and Stroke Rates in Unruptured Brain Arteriovenous Malformations in the Post-ARUBA Era // Nauka i Zdravookhranenie [Science & Healthcare]. 2024. Vol.26 (2). pp. 113-120. doi 10.34689/SH.2024.26.2.015Related publications:
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