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.).
Stroke. 2016 Feb;47(2):342-9. doi: 10.1161/STROKEAHA.115.011400. Epub 2015 Dec 10.
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.
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.
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.
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.
由于 ARUBA 试验（一项关于未破裂脑动静脉畸形的随机试验）的结果表明保守治疗具有更好的临床结局，因此干预治疗未破裂脑动静脉畸形（AVM）患者的获益受到了质疑。本多中心回顾性队列研究的目的是分析符合 ARUBA 标准的患者接受立体定向放射外科手术的结果。
我们合并了 7 家参与国际伽玛刀研究基金会的机构的 AVM 放射外科手术结果数据。筛选出至少有 12 个月随访的患者，以确定其是否符合 ARUBA 标准。良好的结局定义为 AVM 闭塞、无放射外科手术后出血、无永久性症状性放射性诱导改变。不良神经学结局定义为任何新发或恶化的神经症状或死亡。
符合 ARUBA 标准的队列包括 509 例患者（平均年龄为 40 岁）。Spetzler-Martin 分级为 I 级至 II 级的占 46%，III 级至 IV 级的占 54%。平均放射外科边缘剂量为 22Gy，随访时间为 86 个月。AVM 闭塞率为 75%。潜伏期内放射外科手术后出血率为每年 0.9%。出现症状性和永久性放射性诱导改变的比例分别为 11%和 3%。良好结局、不良神经学结局、永久性神经发病率和死亡率的发生率分别为 70%、13%、5%和 4%。
放射外科手术可能为一些符合 ARUBA 标准的患者提供持久的临床获益。基于 ARUBA 试验中未破裂 AVM 自然史的医疗组，我们估计需要 15 至 20 年的随访时间，才能实现放射外科干预治疗未破裂 AVM 患者的保守治疗的潜在获益。
