Interventions for Treating Brain Arteriovenous Malformations in Adults
- cerebral aneurysm
- cerebral arteriovenous malformations
- subarachnoid hemorrhage
- cerebral hemorrhage
- intracerebral hemorrhage
Various interventions have been used—either alone or in staged combinations—when trying to eradicate the nidus of a brain arteriovenous malformation (AVM): neurosurgical excision, stereotactic radiotherapy/“radiosurgery” (using gamma knife, linear accelerator, or proton beam), or endovascular embolization (using glues, particles, fibers, coils, or balloons).
To assess the clinical effects of interventions to treat brain AVMs in adults (with the aim of either partial obliteration or total eradication) using data published in randomized controlled trials (RCTs).
We searched: (1) the Cochrane Stroke Group Register (last searched December 2004); (2) medical literature databases (MEDLINE 1966 to December 31, 2004 and EMBASE 1980 to December 31, 2004); (3) online and paper journal surveillance; (4) the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2005); (5) international registers of clinical trials; (6) bibliographies of relevant articles identified by (1) to (5); and (7) we sought unpublished data from manufacturers of interventional treatments for brain AVMs.
We sought RCTs of any or all of the interventions for brain AVMs, compared against each other or against usual medical therapy, with relevant clinical outcome measures.
Data Collection and Analysis
Two authors independently applied the inclusion criteria and reviewed the relevant studies.
We did not find any RCTs meeting our selection criteria. We found just 2 RCTs that tested the equivalence of 2 embolic agents for the preoperative embolization of brain AVMs (1 published, 1 unpublished), but none of the primary or secondary outcome measures in these 2 trials met our desired criteria; although important clinical outcomes were reported, meaningful comparison of the 2 treatment arms was impossible.
Implications for Practice
There are no RCTs to influence the choice of interventional treatment for brain AVMs in clinical practice. The decision to treat is only informed by indirect comparisons of the outcome of case series without a control group, and personal experience.
Implications for Research
There are currently grounds for 2 types of RCTs. First, a policy of interventional treatment should be compared against usual medical therapy for unruptured brain AVMs (Figure); 1 such RCT is underway (http://www.arubastudy.org). Second, different interventions should be compared against each other in a randomized trial for the treatment of both ruptured and unruptured brain AVMs (Figure).
Note: The full text of this review is available in the Cochrane Library (for subscribers http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003436/frame.html). The full article should be cited as: Al-Shahi R, Warlow CP. Interventions for treating brain arteriovenous malformations in adults. Cochrane Database Syst Rev. 2006. Issue 1. Art. No.: CD003436. DOI: 10.1002/14651858.CD003436.pub2.
- Received November 30, 2005.
- Accepted December 9, 2005.