Snyder M Harrison, Chen Ching-Jen, Farzad Faraz, Ironside Natasha, Kellogg Ryan T, Southerland Andrew M, Park Min S, Sheehan Jason P, Ding Dale
Departments of1Neurological Surgery.
2Neurology, and.
J Neurosurg. 2021 Nov 5;137(1):108-120. doi: 10.3171/2021.7.JNS211186. Print 2022 Jul 1.
A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that medical management afforded outcomes superior to those following intervention for unruptured arteriovenous malformations (AVMs), but its findings have been controversial. Subsequent studies of AVMs that would have met the eligibility requirements of ARUBA have supported intervention for the management of some cases. The present meta-analysis was conducted with the object of summarizing interventional outcomes for ARUBA-eligible patients reported in the literature.
A systematic literature search (PubMed, Web of Science, Google Scholar) for AVM intervention studies that used inclusion criteria identical to those of ARUBA (age ≥ 18 years, no history of AVM hemorrhage, no prior intervention) was performed. The primary outcome was death or symptomatic stroke. Secondary outcomes included AVM obliteration, hemorrhage, death, and poor outcome (modified Rankin Scale score ≥ 2 at final follow-up). Bias assessment was performed with the Newcastle-Ottawa Scale, and the results were synthesized as pooled proportions.
Of the 343 articles identified through database searches, 13 studies met the inclusion criteria, yielding an overall study cohort of 1909 patients. The primary outcome occurred in 11.2% of patients (pooled = 11%, 95% CI 8%-13%). The rates of AVM obliteration, hemorrhage, poor outcome, and death were 72.7% (pooled = 78%, 95% CI 70%-85%), 8.4% (pooled = 8%, 95% CI 6%-11%), 9.9% (pooled = 10%, 95% CI 7%-13%), and 3.5% (pooled = 2%, 95% CI 1%-4%), respectively. Annualized primary outcome and hemorrhage risks were 1.85 (pooled = 2.05, 95% CI 1.31-2.94) and 1.34 (pooled = 1.41, 95% CI 0.83-2.13) per 100 patient-years, respectively.
Intervention for unruptured AVMs affords acceptable outcomes for appropriately selected patients. The risk of hemorrhage following intervention compared favorably to the natural history of unruptured AVMs. The included studies were retrospective and varied in treatment and AVM characteristics, thereby limiting the generalizability of their data. Future studies from prospective registries may clarify patient, nidus, and intervention selection criteria that will refine the challenging management of patients with unruptured AVMs.
未破裂脑动静脉畸形随机试验（ARUBA）表明，对于未破裂动静脉畸形（AVM），保守治疗的效果优于干预治疗，但其研究结果存在争议。随后对符合ARUBA纳入标准的AVM进行的研究支持对部分病例进行干预治疗。本荟萃分析旨在总结文献中报道的符合ARUBA标准患者的干预治疗结果。
通过系统文献检索（PubMed、科学网、谷歌学术），查找使用与ARUBA相同纳入标准（年龄≥18岁、无AVM出血史、无既往干预治疗史）的AVM干预研究。主要结局为死亡或有症状性卒中。次要结局包括AVM闭塞、出血、死亡以及不良结局（末次随访时改良Rankin量表评分≥2分）。采用纽卡斯尔-渥太华量表进行偏倚评估，并将结果合并为合并比例。
通过数据库检索确定的343篇文章中，13项研究符合纳入标准，共纳入1909例患者。主要结局发生在11.2%的患者中（合并比例=11%，95%CI 8%-13%）。AVM闭塞、出血、不良结局和死亡的发生率分别为72.7%（合并比例=78%，95%CI 70%-85%）、8.4%（合并比例=8%，95%CI 6%-11%）、9.9%（合并比例=10%，95%CI 7%-13%）和3.5%（合并比例=2%，95%CI 1%-4%）。每100患者年的年化主要结局和出血风险分别为1.85（合并比例=2.05，95%CI 1.31-2.94）和1.34（合并比例=1.41，95%CI 0.83-2.13）。
对于适当选择的患者，未破裂AVM的干预治疗可获得可接受的结果。干预治疗后的出血风险优于未破裂AVM的自然病程。纳入的研究为回顾性研究，治疗方法和AVM特征各不相同，因此限制了其数据的可推广性。未来来自前瞻性登记处的研究可能会明确患者、病灶和干预选择标准，从而优化未破裂AVM患者具有挑战性的治疗管理。
