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Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial

2022; American Association of Neurological Surgeons; Linguagem: Inglês

10.3171/2022.7.jns22813

1933-0693

Tim E. Darsaut, Elsa Magro, Michel W. Bojanowski, Chiraz Chaalala, Lorena Nico, Emma Bacchus, Ruby Klink, Daniela Iancu, Alain Weill, Daniel Roy, Jean-François Sabatier, Christophe Cognard, Anne-Christine Januel, I. Pélissou-Guyotat, Omer Eker, Pièrre-Hugues Roche, Thomas Graillon, Hervé Brunel, F. Proust, Rémy Beaujeux, Sorin Aldéa, Michel Piotin, Philippe Cornu, Eimad Shotar, Thomas Gaberel, Charlotte Barbier, Marine Le Corre, Vincent Costalat, Vincent Jecko, Xavier Barreau, Xavier Morandi, Jean‐Yves Gauvrit, Stéphane Derrey, Chrysanthi Papagiannaki, Thanh N. Nguyen, Mohamad Abdalkader, Rabih G. Tawk, Thien Huynh, Geraldine Viard, Guylaine Gévry, Jean‐Christophe Gentric, Jean Raymond, NULL AUTHOR_ID, NULL AUTHOR_ID, Jean Raymond, Daniel Roy, Alain Weill, Daniela Iancu, Michel W. Bojanowski, Chiraz Chaalala, Tim E. Darsaut, Jeremy Rempel, Cian O’Kelly, Michael M. C. Chow, J. Max Findlay, Robert Fahed, Howard Lesiuk, Brian Drake, M Santos, Jean‐Christophe Gentric, Elsa Magro, Romuald Seizeur, Michel Nonent, Serge Timsit, Olivier Pradier, Julien Ognard, Mourad Cheddad El Aouni, Hubert Desal, Romain Boursier, F. Thillays, Vincent Roualdes, Michel Piotin, Sorin Aldéa, Raphaël Blanc, Christophe Cognard, Anne-Christine Januel, Jean-François Sabatier, Lionel Calviere, J.Y. Gauvrit, Isabelle Lecouillard, Xavier Morandi, Elodie Nouhaud, Hélène Raoult, François Eugene, Anthony Le Bras, Jean‐Christophe Ferré, Christophe Paya, Thomas Ronzière, D. Trystram, Olivier Naggara, Christine Rodriguez-Régent, Basile Kerleroux, Thomas Gaberel, Charlotte Barbier, Evelyne Emery, Emmanuel Touze, Chrysanthi Papagiannaki, Stéphane Derrey, Isabelle Pellisou-Guyotat, Omer Eker, Jacques Guyotat, Monsef Berhouma, Roberto Riva, Chloé Dumot, Alessandra Biondi, L. Thines, Guillaume Charbonnier, Nassim Bougaci, Serge Bracard, René Anxionnat, Valérie Bernier-Chastagner, Thierry Civit, Benjamin Gory, Xavier Barreau, Vincent Jecko, Guillaume Penchet, Edouard Gimbert, Gaulthier Marnat, Aymeri Huchet, Denis Herbreteau, Grégoire Boulouis, Stéphane Velut, Richard Bibi, Héloïse Ifergan, Kévin Janot, Pièrre-Hugues Roche, Thomas Graillon, Hervé Brunel, Hadrien Peyriere, Jean-Marc Kaya, Adamou Touta, Lucas Troude, Sébastien Boissonneau, Eimad Shotar, Anne‐Laure Boch, Philippe Cornu, Frédéric Clarençon, Nader Sourour, Aurélien Nouet, Stéphanie Lenck, Kévin Premat, Vincent Costalat, Marine Le Corre, Alain Bonafé, Cyril Dargazanli, Gregory Gascou, Pierre-Henri Lefevre, Carlos Riquelme, F. Proust, Rémy Beaujeux, H. Cébula, Irène Ollivier, Raoul Pop, Giorgio Spatola, Laurent Spelle, Vanessa Chalumeau, Sophie Gallas, Léon Ikka, Cristian Mihalea, Augustin Ozanne, Jildaz Caroff, Emmanuel Chabert, Charbel Mounayer, Aymeric Rouchaud, François Caire, F. Ricolfi, Catherine Cao, Klaus-Luc Mourier, Pierre Thouant, Walid Farah, Thanh N. Nguyen, Mohamad Abdalkader, Rabih G. Tawk, Thien Huynh, Andrew P. Carlson, Luciana Alves Oliveira Silva, Nayara de Lima Froio, Gisele Sampaio Silva, Francisco J. A. Mont’Alverne, Jose Luri Martins, George Nilton Nunes Mendes, Rodrigo Rivera Miranda,

Meningioma and schwannoma management

OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I–II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%–93%) and 105/110 low-grade (95%, 95% CI 90%–98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%–18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%–28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%–9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 ( ClinicalTrials.gov )