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

For those with AVMs.
http://strokeblog.strokeahajournal.org/2016/02/stereotactic-radiosurgery-leads-to-good.html

A Multicenter Study

1. Dale Ding, MD;
2. Robert M. Starke, MD, MSc;
3. Hideyuki Kano, MD;
4. David Mathieu, MD;
5. Paul Huang, MD;
6. Douglas Kondziolka, MD;
7. Caleb Feliciano, MD;
8. Rafael Rodriguez-Mercado, MD;
9. Luis Almodovar, MD;
10. Inga S. Grills, MD;
11. Danilo Silva, MD;
12. Mahmoud Abbassy, MD;
13. Symeon Missios, MD;
14. Gene H. Barnett, MD;
15. L. Dade Lunsford, MD;
16. Jason P. Sheehan, MD, PhD

+ Author Affiliations

1. From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.).

1. Correspondence to Jason Sheehan, MD, PhD, Department of Neurosurgery, University of Virginia, PO Box 800212, Charlottesville, VA 22908. E-mail jps2f@virginia.edu

Abstract

Background and Purpose—The benefit of intervention for patients with unruptured cerebral arteriovenous malformations (AVMs) was challenged by results demonstrating superior clinical outcomes with conservative management from A Randomized Trial of Unruptured Brain AVMs (ARUBA). The aim of this multicenter, retrospective cohort study is to analyze the outcomes of stereotactic radiosurgery for ARUBA-eligible patients.

Methods—We combined AVM radiosurgery outcome data from 7 institutions participating in the International Gamma Knife Research Foundation. Patients with ≥12 months of follow-up were screened for ARUBA eligibility criteria. Favorable outcome was defined as AVM obliteration, no postradiosurgery hemorrhage, and no permanently symptomatic radiation–induced changes. Adverse neurological outcome was defined as any new or worsening neurological symptoms or death.

Results—The ARUBA-eligible cohort comprised 509 patients (mean age, 40 years). The Spetzler–Martin grade was I to II in 46% and III to IV in 54%. The mean radiosurgical margin dose was 22 Gy and follow-up was 86 months. AVM obliteration was achieved in 75%. The postradiosurgery hemorrhage rate during the latency period was 0.9% per year. Symptomatic and permanent radiation–induced changes occurred in 11% and 3%, respectively. The rates of favorable outcome, adverse neurological outcome, permanent neurological morbidity, and mortality were 70%, 13%, 5%, and 4%, respectively.

Conclusions—Radiosurgery may provide durable clinical benefit in some ARUBA-eligible patients. On the basis of the natural history of untreated, unruptured AVMs in the medical arm of ARUBA, we estimate that a follow-up duration of 15 to 20 years is necessary to realize a potential benefit of radiosurgical intervention for conservative management in unruptured patients with AVM