Nerva John D, Mantovani Alessandra, Barber Jason, Kim Louis J, Rockhill Jason K, Hallam Danial K, Ghodke Basavaraj V, Sekhar Laligam N
*Department of Neurological Surgery, ‡Radiology, and §Radiation Oncology, University of Washington, Seattle, Washington.
Neurosurgery. 2015 May;76(5):563-70; discussion570; quiz 570. doi: 10.1227/NEU.0000000000000663.
The design and conclusions of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial are controversial, and its structure limits analysis of patients who could potentially benefit from treatment.
To analyze the results of a consecutive series of patients with unruptured brain arteriovenous malformations (BAVMs), including a subgroup analysis of ARUBA-eligible patients.
One hundred five patients with unruptured BAVMs were treated over an 8-year period. From this series, 90 adult patients and a subgroup of 61 patients determined to be ARUBA eligible were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades I/II, III, and IV/V was performed. The modified Rankin Scale was used to assess functional outcome.
Persistent deficits, modified Rankin Scale score deterioration, and impaired functional outcome occurred less frequently in ARUBA-eligible grade I/II patients compared with grade III to V patients combined (P = .04, P = .04, P = .03, respectively). Twenty-two of 39 patients (56%) unruptured grade I and II BAVMs were treated with surgery without and with preoperative embolization, and all had a modified Rankin Scale score of 0 to 1 at the last follow-up. All patients treated with surgery without and with preoperative embolization had radiographic cure at the last follow-up.
The results of ARUBA-eligible and unruptured grade I/II patients overall show that excellent outcomes can be obtained in this subgroup of patients, especially with surgical management. Functional outcomes for ARUBA-eligible patients were similar to those of patients who were randomized to medical management in ARUBA. On the basis of these data, in appropriately selected patients, we recommend treatment for low-grade BAVMs.
未破裂脑动静脉畸形随机试验（ARUBA）的设计和结论存在争议，其结构限制了对可能从治疗中获益患者的分析。
分析一系列连续的未破裂脑动静脉畸形（BAVM）患者的结果，包括对符合ARUBA标准患者的亚组分析。
在8年期间对105例未破裂BAVM患者进行了治疗。从该系列中，回顾性分析了90例成年患者以及确定符合ARUBA标准的61例患者亚组。对Spetzler-Martin分级I/II、III和IV/V进行了亚组分析。采用改良Rankin量表评估功能结局。
与III至V级患者合并组相比，符合ARUBA标准的I/II级患者持续神经功能缺损、改良Rankin量表评分恶化及功能结局受损的发生率更低（分别为P = 0.04、P = 0.04、P = 0.03）。39例未破裂I级和II级BAVM患者中有22例（56%）接受了手术治疗，其中部分患者术前未行栓塞，部分患者术前进行了栓塞，所有患者在末次随访时改良Rankin量表评分为0至1分。所有接受手术治疗（无论术前是否行栓塞）的患者在末次随访时影像学显示治愈。
总体而言，符合ARUBA标准的未破裂I/II级患者的结果表明，该亚组患者可获得良好结局，尤其是手术治疗。符合ARUBA标准患者的功能结局与ARUBA试验中随机接受保守治疗患者的结局相似。基于这些数据，对于适当选择的患者，我们建议对低级别BAVM进行治疗。
