Wong Johnny, Slomovic Alana, Ibrahim George, Radovanovic Ivan, Tymianski Michael
From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.).
Stroke. 2017 Jan;48(1):136-144. doi: 10.1161/STROKEAHA.116.014660. Epub 2016 Nov 17.
The management of unruptured brain arteriovenous malformations (ubAVMs) remains controversial despite ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation), a controlled trial that suggested superiority of conservative management over intervention. However, microsurgery occurred in only 14.9% of ARUBA intervention cases, raising concerns about the study's generalizability. Our purpose was to evaluate whether, in a larger ARUBA-eligible ubAVM population, microsurgery produces acceptable outcomes.
Demographic data, AVM characteristics, and treatment outcomes were evaluated in 155 ARUBA-eligible bAVMs treated with microsurgery between 1994 and 2014. Outcomes were rates of early disabling deficits and permanent disabling deficits with modified Rankin Scale score ≥3 or any permanent neurological deficits with modified Rankin Scale score ≥1. Covariates associated with outcomes were determined by regression analysis.
Of 977 AVM patients, 155 ARUBA-eligible patients had microsurgical resection (71.6% surgery only and 25.2% with preoperative embolization). Mean follow-up was 36.1 months. Complete obliteration was achieved in 94.2% after initial surgery and 98.1% on final angiography. Early disabling deficits and permanent disabling deficits occurred in 12.3% and 4.5%, respectively, whereas any permanent neurological deficit (modified Rankin Scale score ≥1) occurred in 16.1%. Among ubAVM of Spetzler-Martin grades 1 and 2, complete obliteration occurred in 99.2%, with early disabling deficits and permanent disabling deficits occurring in 9.3% and 3.4%, respectively. Major bleeding was the only significant predictor of early disabling deficits on multivariate analysis (P<0.001).
Microsurgery in this cohort produced less disabling deficits than ARUBA with similar morbidity and AVM obliteration as other cohort series. This disparity between our results and ARUBA suggests that future controlled trials should focus on the safety and efficacy of microsurgery with or without adjunctive embolization in carefully selected ubAVM patients.
尽管有ARUBA试验（未破裂脑动静脉畸形随机试验）表明保守治疗优于干预治疗，但未破裂脑动静脉畸形（ubAVM）的治疗仍存在争议。然而，在ARUBA试验的干预病例中，只有14.9%的患者接受了显微手术，这引发了对该研究可推广性的担忧。我们的目的是评估在更大的符合ARUBA标准的ubAVM患者群体中，显微手术是否能产生可接受的结果。
对1994年至2014年间接受显微手术治疗的155例符合ARUBA标准的脑动静脉畸形（bAVM）患者的人口统计学数据、动静脉畸形特征和治疗结果进行评估。结果指标为早期致残性神经功能缺损和改良Rankin量表评分≥3的永久性致残性神经功能缺损，或改良Rankin量表评分≥1的任何永久性神经功能缺损。通过回归分析确定与结果相关的协变量。
在977例动静脉畸形患者中，155例符合ARUBA标准的患者接受了显微手术切除（71.6%仅接受手术，25.2%接受术前栓塞）。平均随访时间为36.1个月。初次手术后94.2%的患者实现了完全闭塞，最终血管造影时为98.1%。早期致残性神经功能缺损和永久性致残性神经功能缺损的发生率分别为12.3%和4.5%，而任何永久性神经功能缺损（改良Rankin量表评分≥1）的发生率为16.1%。在Spetzler-Martin 1级和2级的ubAVM中，完全闭塞率为99.2%，早期致残性神经功能缺损和永久性致残性神经功能缺损的发生率分别为9.3%和3.4%。多因素分析显示，大出血是早期致残性神经功能缺损的唯一显著预测因素（P<0.001）。
该队列中的显微手术导致的致残性神经功能缺损少于ARUBA试验，且发病率和动静脉畸形闭塞情况与其他队列系列相似。我们的结果与ARUBA试验之间的差异表明，未来的对照试验应关注在精心挑选的ubAVM患者中，显微手术联合或不联合辅助栓塞的安全性和有效性。
