Department of Neurosurgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
Acta Neurochir (Wien). 2023 Dec;165(12):3779-3785. doi: 10.1007/s00701-023-05815-z. Epub 2023 Oct 2.
The first randomized controlled study on unruptured brain arteriovenous malformations (bAVM), the ARUBA trial, demonstrate the superiority of medical management; however, it failed to completely rule out the efficacy of therapeutic interventions due to several limitations. This study aimed to examine the outcomes of multimodal interventional treatment for bAVM in terms of safety and efficacy.
We reviewed 226 consecutive patients with unruptured bAVM admitted to our institute between 2002 and 2022. Treatment methods were divided into medical management and therapeutic intervention, including microsurgery, stereotactic surgery, and endovascular intervention. First, the choice of therapeutic modalities was assessed in the pre-ARUBA (before February 2014) and post-ARUBA (after March 2014) eras. Second, the incidence of symptomatic stroke or death and functional prognosis with a modified Rankin scale (mRS) score of ≥2 at 5 years was compared between the medical management and therapeutic intervention.
In the pre- and post-ARUBA groups, 73% and 84% of patients underwent therapeutic interventions, respectively (p = 0.053). The rate of symptomatic stroke or death was lower in patients who underwent interventional therapies than in those who underwent medical management (9.7% vs. 22%, p = 0.022); however, the opposite was observed in the ARUBA trial (31% vs. 10%). The annual incidence of stroke or death was also lower in the interventional therapy group (4.3%/y vs. 1.8%/year, hazard ratio = 0.45, 95% confidence interval: 0.18-1.08, p = 0.032). The rate of mRS score of ≥2 after a 5-year follow-up was 18% and 6% in the medical treatment and intervention groups (p = 0.14).
The therapeutic intervention rate did not decrease, even after the publication of the ARUBA trial. The rate of stroke or death was lower in the intervention group, indicating that a tailored choice of multimodality is safe and effective for managing unruptured bAVM.
第一项关于未破裂脑动静脉畸形（bAVM）的随机对照研究——ARUBA 试验表明，药物治疗具有优越性；然而，由于存在一些局限性，该试验未能完全排除治疗干预的疗效。本研究旨在探讨多模态介入治疗未破裂 bAVM 的安全性和有效性。
我们回顾了 2002 年至 2022 年期间我院收治的 226 例未破裂 bAVM 患者。治疗方法分为药物治疗和治疗干预，包括显微手术、立体定向手术和血管内介入治疗。首先，在 ARUBA 前（2014 年 2 月前）和 ARUBA 后（2014 年 3 月后）两个时期评估治疗方式的选择。其次，比较药物治疗和治疗干预 5 年后症状性卒中和死亡发生率以及改良 Rankin 量表（mRS）评分≥2 的功能预后。
ARUBA 前和 ARUBA 后组分别有 73%和 84%的患者接受了治疗干预（p=0.053）。与药物治疗组相比，接受介入治疗的患者发生症状性卒中和死亡的风险较低（9.7% vs. 22%，p=0.022）；然而，ARUBA 试验中观察到的结果则相反（31% vs. 10%）。介入治疗组的卒中或死亡年发生率也较低（4.3%/年 vs. 1.8%/年，风险比=0.45，95%置信区间：0.18-1.08，p=0.032）。药物治疗和介入治疗组 5 年随访后 mRS 评分≥2 的比例分别为 18%和 6%（p=0.14）。
即使在 ARUBA 试验发表后，治疗干预的比例也没有下降。介入治疗组的卒中或死亡发生率较低，表明针对未破裂 bAVM 采用多模态个体化治疗是安全有效的。
