Outcome after conservative management or intervention for unruptured brain arteriovenous malformations

Rustam Al-Shahi Salman, Philip M White, Carl E Counsell, Johann du Plessis, Janneke van Beijnum, Colin B Josephson, Tim Wilkinson, Catherine J Wedderburn, Zoe Chandy, E Jerome St George, Robin J Sellar, Charles P Warlow, Scottish Audit of Intracranial Vascular Malformations Collaborators

Research output: Contribution to journalArticle

130 Citations (Scopus)

Abstract

Importance Whether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.

Objective To compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.

Design, Setting, and Population Population-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999-2003 or 2006-2010 and followed up prospectively for 12 years.

Exposures Conservative management (no intervention) vs intervention (any endovascular embolization, neurosurgical excision, or stereotactic radiosurgery alone or in combination).

Main Outcomes and Measures Cox regression analyses, with multivariable adjustment for prognostic factors and baseline imbalances if hazards were proportional, to compare rates of the primary outcome (death or sustained morbidity of any cause by Oxford Handicap Scale [OHS] score ≥2 for ≥2 successive years [0 = no symptoms and 6 = death]) and the secondary outcome (nonfatal symptomatic stroke or death due to bAVM, associated arterial aneurysm, or intervention).

Results Of 204 patients, 103 underwent intervention. Those who underwent intervention were younger, more likely to have presented with seizure, and less likely to have large bAVMs than patients managed conservatively. During a median follow-up of 6.9 years (94% completeness), the rate of progression to the primary outcome was lower with conservative management during the first 4 years of follow-up (36 vs 39 events; 9.5 vs 9.8 per 100 person-years; adjusted hazard ratio, 0.59; 95% CI, 0.35-0.99), but rates were similar thereafter. The rate of the secondary outcome was lower with conservative management during 12 years of follow-up (14 vs 38 events; 1.6 vs 3.3 per 100 person-years; adjusted hazard ratio, 0.37; 95% CI, 0.19-0.72).

Conclusions and Relevance Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.
Original languageEnglish
Pages (from-to)1661-1669
Number of pages9
JournalJAMA
Volume311
Issue number16
DOIs
Publication statusPublished - 2014

Fingerprint

Arteriovenous Malformations
Brain
Radiosurgery
Scotland
Population
Aneurysm
Conservative Treatment
Seizures
Cohort Studies
Stroke
Regression Analysis
Outcome Assessment (Health Care)
Morbidity

Keywords

  • Adult
  • Aged
  • Cohort Studies
  • Embolization, Therapeutic
  • Female
  • Humans
  • Intracranial Arteriovenous Malformations
  • Male
  • Middle Aged
  • Neurosurgical Procedures
  • Radiosurgery
  • Scotland
  • Survival Analysis
  • Treatment Outcome
  • Watchful Waiting

Cite this

Al-Shahi Salman, R., White, P. M., Counsell, C. E., du Plessis, J., van Beijnum, J., Josephson, C. B., ... Scottish Audit of Intracranial Vascular Malformations Collaborators (2014). Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA, 311(16), 1661-1669. https://doi.org/10.1001/jama.2014.3200

Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. / Al-Shahi Salman, Rustam; White, Philip M; Counsell, Carl E; du Plessis, Johann; van Beijnum, Janneke; Josephson, Colin B; Wilkinson, Tim; Wedderburn, Catherine J; Chandy, Zoe; St George, E Jerome; Sellar, Robin J; Warlow, Charles P; Scottish Audit of Intracranial Vascular Malformations Collaborators.

In: JAMA, Vol. 311, No. 16, 2014, p. 1661-1669.

Research output: Contribution to journalArticle

Al-Shahi Salman, R, White, PM, Counsell, CE, du Plessis, J, van Beijnum, J, Josephson, CB, Wilkinson, T, Wedderburn, CJ, Chandy, Z, St George, EJ, Sellar, RJ, Warlow, CP & Scottish Audit of Intracranial Vascular Malformations Collaborators 2014, 'Outcome after conservative management or intervention for unruptured brain arteriovenous malformations', JAMA, vol. 311, no. 16, pp. 1661-1669. https://doi.org/10.1001/jama.2014.3200
Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB et al. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA. 2014;311(16):1661-1669. https://doi.org/10.1001/jama.2014.3200
Al-Shahi Salman, Rustam ; White, Philip M ; Counsell, Carl E ; du Plessis, Johann ; van Beijnum, Janneke ; Josephson, Colin B ; Wilkinson, Tim ; Wedderburn, Catherine J ; Chandy, Zoe ; St George, E Jerome ; Sellar, Robin J ; Warlow, Charles P ; Scottish Audit of Intracranial Vascular Malformations Collaborators. / Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. In: JAMA. 2014 ; Vol. 311, No. 16. pp. 1661-1669.
@article{8017828fd67248a2bb4db7eeefa7207e,
title = "Outcome after conservative management or intervention for unruptured brain arteriovenous malformations",
abstract = "Importance Whether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.Objective To compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.Design, Setting, and Population Population-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999-2003 or 2006-2010 and followed up prospectively for 12 years.Exposures Conservative management (no intervention) vs intervention (any endovascular embolization, neurosurgical excision, or stereotactic radiosurgery alone or in combination).Main Outcomes and Measures Cox regression analyses, with multivariable adjustment for prognostic factors and baseline imbalances if hazards were proportional, to compare rates of the primary outcome (death or sustained morbidity of any cause by Oxford Handicap Scale [OHS] score ≥2 for ≥2 successive years [0 = no symptoms and 6 = death]) and the secondary outcome (nonfatal symptomatic stroke or death due to bAVM, associated arterial aneurysm, or intervention).Results Of 204 patients, 103 underwent intervention. Those who underwent intervention were younger, more likely to have presented with seizure, and less likely to have large bAVMs than patients managed conservatively. During a median follow-up of 6.9 years (94{\%} completeness), the rate of progression to the primary outcome was lower with conservative management during the first 4 years of follow-up (36 vs 39 events; 9.5 vs 9.8 per 100 person-years; adjusted hazard ratio, 0.59; 95{\%} CI, 0.35-0.99), but rates were similar thereafter. The rate of the secondary outcome was lower with conservative management during 12 years of follow-up (14 vs 38 events; 1.6 vs 3.3 per 100 person-years; adjusted hazard ratio, 0.37; 95{\%} CI, 0.19-0.72).Conclusions and Relevance Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.",
keywords = "Adult, Aged, Cohort Studies, Embolization, Therapeutic, Female, Humans, Intracranial Arteriovenous Malformations, Male, Middle Aged, Neurosurgical Procedures, Radiosurgery, Scotland, Survival Analysis, Treatment Outcome, Watchful Waiting",
author = "{Al-Shahi Salman}, Rustam and White, {Philip M} and Counsell, {Carl E} and {du Plessis}, Johann and {van Beijnum}, Janneke and Josephson, {Colin B} and Tim Wilkinson and Wedderburn, {Catherine J} and Zoe Chandy and {St George}, {E Jerome} and Sellar, {Robin J} and Warlow, {Charles P} and {Scottish Audit of Intracranial Vascular Malformations Collaborators}",
year = "2014",
doi = "10.1001/jama.2014.3200",
language = "English",
volume = "311",
pages = "1661--1669",
journal = "JAMA",
issn = "0098-7484",
publisher = "American Medical Association",
number = "16",

}

TY - JOUR

T1 - Outcome after conservative management or intervention for unruptured brain arteriovenous malformations

AU - Al-Shahi Salman, Rustam

AU - White, Philip M

AU - Counsell, Carl E

AU - du Plessis, Johann

AU - van Beijnum, Janneke

AU - Josephson, Colin B

AU - Wilkinson, Tim

AU - Wedderburn, Catherine J

AU - Chandy, Zoe

AU - St George, E Jerome

AU - Sellar, Robin J

AU - Warlow, Charles P

AU - Scottish Audit of Intracranial Vascular Malformations Collaborators

PY - 2014

Y1 - 2014

N2 - Importance Whether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.Objective To compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.Design, Setting, and Population Population-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999-2003 or 2006-2010 and followed up prospectively for 12 years.Exposures Conservative management (no intervention) vs intervention (any endovascular embolization, neurosurgical excision, or stereotactic radiosurgery alone or in combination).Main Outcomes and Measures Cox regression analyses, with multivariable adjustment for prognostic factors and baseline imbalances if hazards were proportional, to compare rates of the primary outcome (death or sustained morbidity of any cause by Oxford Handicap Scale [OHS] score ≥2 for ≥2 successive years [0 = no symptoms and 6 = death]) and the secondary outcome (nonfatal symptomatic stroke or death due to bAVM, associated arterial aneurysm, or intervention).Results Of 204 patients, 103 underwent intervention. Those who underwent intervention were younger, more likely to have presented with seizure, and less likely to have large bAVMs than patients managed conservatively. During a median follow-up of 6.9 years (94% completeness), the rate of progression to the primary outcome was lower with conservative management during the first 4 years of follow-up (36 vs 39 events; 9.5 vs 9.8 per 100 person-years; adjusted hazard ratio, 0.59; 95% CI, 0.35-0.99), but rates were similar thereafter. The rate of the secondary outcome was lower with conservative management during 12 years of follow-up (14 vs 38 events; 1.6 vs 3.3 per 100 person-years; adjusted hazard ratio, 0.37; 95% CI, 0.19-0.72).Conclusions and Relevance Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.

AB - Importance Whether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.Objective To compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.Design, Setting, and Population Population-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999-2003 or 2006-2010 and followed up prospectively for 12 years.Exposures Conservative management (no intervention) vs intervention (any endovascular embolization, neurosurgical excision, or stereotactic radiosurgery alone or in combination).Main Outcomes and Measures Cox regression analyses, with multivariable adjustment for prognostic factors and baseline imbalances if hazards were proportional, to compare rates of the primary outcome (death or sustained morbidity of any cause by Oxford Handicap Scale [OHS] score ≥2 for ≥2 successive years [0 = no symptoms and 6 = death]) and the secondary outcome (nonfatal symptomatic stroke or death due to bAVM, associated arterial aneurysm, or intervention).Results Of 204 patients, 103 underwent intervention. Those who underwent intervention were younger, more likely to have presented with seizure, and less likely to have large bAVMs than patients managed conservatively. During a median follow-up of 6.9 years (94% completeness), the rate of progression to the primary outcome was lower with conservative management during the first 4 years of follow-up (36 vs 39 events; 9.5 vs 9.8 per 100 person-years; adjusted hazard ratio, 0.59; 95% CI, 0.35-0.99), but rates were similar thereafter. The rate of the secondary outcome was lower with conservative management during 12 years of follow-up (14 vs 38 events; 1.6 vs 3.3 per 100 person-years; adjusted hazard ratio, 0.37; 95% CI, 0.19-0.72).Conclusions and Relevance Among patients aged 16 years or older diagnosed as having unruptured bAVM, use of conservative management compared with intervention was associated with better clinical outcomes for up to 12 years. Longer follow-up is required to understand whether this association persists.

KW - Adult

KW - Aged

KW - Cohort Studies

KW - Embolization, Therapeutic

KW - Female

KW - Humans

KW - Intracranial Arteriovenous Malformations

KW - Male

KW - Middle Aged

KW - Neurosurgical Procedures

KW - Radiosurgery

KW - Scotland

KW - Survival Analysis

KW - Treatment Outcome

KW - Watchful Waiting

U2 - 10.1001/jama.2014.3200

DO - 10.1001/jama.2014.3200

M3 - Article

VL - 311

SP - 1661

EP - 1669

JO - JAMA

JF - JAMA

SN - 0098-7484

IS - 16

ER -