Reimagining ARUBA: Theoretical Optimization of the Treatment of Unruptured Brain Arteriovenous Malformations.

BACKGROUND AND PURPOSE: The results of the A Randomized Trial of Unruptured Brain Arteriovenous (ARUBA) study, indicating that conservative medical management of unruptured brain arteriovenous malformations (UBAVM) is superior to interventional therapy, have generated debates that have hampered their application into clinical practice. Irrespectively of study conclusions, it seems reasonable to explore how much better interventional therapy would have to be to become competitive with conservative medical management. METHODS: We conducted an exploratory analysis to replicate the original data from ARUBA. The functional form of the replicated ARUBA data, according to their Weibull distribution, allowed estimation of parameters. We carried out Monte Carlo simulations while introducing theoretical reductions of interventional risk, and the results were used to construct theoretical and example Kaplan-Meier curves from simulations. RESULTS: The "ARUBA Replication" analysis showed results nearly identical to those published in the study, with an estimated hazard ratio of 0.27 (95% CI: 0.14-0.55). At 50% interventional risk reduction, the simulations showed an estimated event rate of 14.9%, and the protective effect of conservative medical management was no longer statistically significant. Greater risk reductions hastened the time to benefit for interventional therapy, and an 80% risk reduction demonstrated superiority of interventional therapy at just over 2 years Hazard Ratio (HR: 1.44, 95% CI: 0.55-4.92). CONCLUSIONS: Reduction in risk of interventional therapy by 50%-80% results in more competitive clinical outcomes, equating or surpassing the benefit of conservative medical management of UBAVM. This conjecture should be taken into consideration in the design of future studies of this patient population, particularly because it is supported by recent observational studies.

Ten-year follow-up of giant basilar aneurysm treated by sole stenting technique: a case report.

INTRODUCTION: The sole stenting technique has emerged as a new tool for the management of intracranial aneurysms. However, several concerns have emerged about the long-term behavior of intracranial stents, particularly their safety and efficacy. CASE PRESENTATION: We present the first case of an intracranial aneurysm intentionally treated with the sole stenting technique. After ten years of clinical and imaging follow-up, the lesion has healed and no intrastent stenosis is observed.Several issues concerning this technique are discussed. For instance, the modification of the angle and intra-aneurysmal thrombosis may account as positive effects; negative outcomes include in-stent thrombosis or stenosis. CONCLUSIONS: This case report, involving a long clinical and imaging follow-up, provides an example of the effectiveness, safety, durability and simplicity of the sole stenting technique in the management of intracranial aneurysms.

Sole stenting bypass for the treatment of vertebral artery aneurysms: technical case report.

OBJECTIVE AND IMPORTANCE: Vertebrobasilar aneurysms have a risk of rupture ranging from 2.5 to 50% (especially those larger than 7 mm) and a repeat bleeding rate of between 30 and 70%. For this reason, patients with aneurysms larger than 7 mm should be treated. Considering the high complexity of surgical approaches in this area, an increasing number of reported cases are being treated with endovascular therapy. The purpose of this article is to determine the effectiveness and safety of sole stenting bypass in the treatment of three consecutive patients with vertebrobasilar aneurysms. CLINICAL PRESENTATION: Three patients (one woman and two men) with vertebrobasilar junction aneurysms were included in this study. Two of the patients presented with subarachnoid hemorrhage. INTERVENTION: An endovascular procedure was performed under general (two patients) or local (one patient) anesthesia and via a right femoral approach. By use of road map guidance, sole Express (one patient) or Express 2 (two patients) coronary stents (Boston Scientific/Scimed, Maple Grove, MN) were deployed on the diseased vessel. When the stent was in place, an immediate partial thrombosis of the aneurysm was observed, related primarily to an intra-aneurysmal flow pattern modification, possibly facilitated by modification of the angle of the parent vessel. Follow-up angiograms showed complete exclusion of the aneurysms within the circulation. Only one patient presented visual deficit as a thrombotic complication, but it disappeared completely 6 months after treatment. CONCLUSION: The sole stenting bypass technique seems to be a good alternative for the treatment of complex vertebral aneurysms by inducing thrombosis of the aneurysm with preservation of the parent vessel lumen.

Fibrinolisis intraarterial en el tratamiento del accidente cerebrovascular isquémico agudo / Intra-arterial fibrinolysis in the treatment of acute ischemic stroke

El uso del tratamiento fibrinolítico intraarterial en el accidente cerebrovascular isquémico agudo representa un adelanto importante para el manejo más efectivo de una situación de emergencia que requiere la atención cercana de neurólogos y neurocirujanos. Las técnicas y dispositivos para la caracterización selectiva continúan desarrollándose y la experiencia en el uso de estos procedimientos avanza rápidamente. El futuro debe demostrar aún las posibilidades plenas del uso de esta metodología en el cuidado de los pacientes con accidente cerebrovascular isquémico

Fibrinolisis intraarterial en el tratamiento del accidente cerebrovascular isquémico agudo / Intra-arterial fibrinolysis in the treatment of acute ischemic stroke

El uso del tratamiento fibrinolítico intraarterial en el accidente cerebrovascular isquémico agudo representa un adelanto importante para el manejo más efectivo de una situación de emergencia que requiere la atención cercana de neurólogos y neurocirujanos. Las técnicas y dispositivos para la caracterización selectiva continúan desarrollándose y la experiencia en el uso de estos procedimientos avanza rápidamente. El futuro debe demostrar aún las posibilidades plenas del uso de esta metodología en el cuidado de los pacientes con accidente cerebrovascular isquémico (AU)