outcome after interventional or conservative management of unruptured brain arteriovenous...
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Outcome after interventional or conservative management of unruptured brain arteriovenous malformations: a prospective, population-based cohort study
Lancet Neurol March 2008
Sajedha Mahmood
Background
AVMs are leading cause of ICH in young adults, but ICH is presenting symptom in only half of AVM diagnoses
Increased detection of incidental, asymptomatic AVMs due to improved imaging
Unruptured AVMs can be treated by intervention to avoid future rupture Risk of complications vs risk of conservative treatment Columbia AVM Databank analysis shows that outcome after
intervention for unruptured AVM worse than conservative management Currently ARRUBA (randomised trial of unruptured brain AVMs)
ongoing This study compares functional outcome of adults with unruptured AVM
following intervention vs observation Prospective, population-based cohort study
Methods
Scottish Intracranial Vascular Malformation Study (SIVMS) Register of patients > 16 years when first diagnosed with any unruptured intracranial
vascular malformation Data from 1999 - 2003 Follow-up data accrued until analysis date 1 October 2007
Demographic data: age, sex, socioeconomic status Clinical data: type of presentation, comorbidities, smoking status, Oxford
Handicap scale at presentation Neuroradiological data: first diagnostic imaging assessed by 2 neuroradiologists
AVM size, venous drainage pattern, function of adjacent brain area, Spetzler-Martin grade, deep brain location, AVM-associated aneurysms
Intervention defined as any type of intervention on AVM or associated aneurysm AVM nidus obliteration confirmed by DSA or MRA
Methods
Follow-up: annual OHS ratings provided by GP Annual survey of medical records for occurrence of ICH, infarction or
focal neurological deficit ICH: defined as symptomatic clinical event with signs of ICH on
imaging, in CSF or post mortem Independent investigator assessed death, infarction, FNDs on basis of
medical records, imaging and pathology Unaware of prognostic features
Analysis
Comparison of demographic, clinical, radiological characteristics Survival analysis:
OHS scores 0-1 vs 2-6 (2= some restrictions to lifestyle, but able to look after themselves)
Time from presentation onwards for conservative management group Time from first intervention for treatment group
Results
229 adults with AVMs 114 presented with unruptured aneurysm 63 of 114 (55%) - interventional treatment - type of treatment decided
by local clinician 51 (45%) - observation 7 patients treated had ICH/infarct/FND between presentation and
intervention Treatment began a median of 1 year after presentation AVM nidus completely obliterated in 42 (67%), partially in 19 (30%), no
data available for 2 (3%) 2 deaths within 3 years after treatment: one partially obliterated AVM
post embolisation, other after radiosurgery with obliterated AVM on imaging few weeks prior to ICH
4 deaths in untreated group: one SAH, others unrelated causes
Conclusions
Intervention and AVM size are predictors of progression to poor outcome (OHS 2-6) in first 3 years
No difference in progression to OHS 2-6 that is sustained until end of year 3 in both arms
No difference in overall spectrum of dependence
Discussion
Thorough case evaluation Prospective annual follow-up Blinded assessment of outcomes Comparison between treated vs untreated OHS as outcome measurement
Prospective cohort study Baseline imbalance between both groups DSA data not available for all patients Short-term follow-up Follow-up by GPs rather than neurologist/neurosurgeon