Overall, despite limitations in design, endovascular technologies, and suboptimal study populations, these reviewed trials provide essential data in the continued refinement of endovascular therapy for large-vessel ischemic stroke. We strongly support further high- quality prospective investigations. In the interim, current data strongly support the reasonable offering of endovascular therapy for patients with LVO. Disclosures Dr Mocco serves a consultant for Endeavor Endovascular and Lazarus Effect. He is an investor in Blockade Medical. Dr Khalessi serves on Clinical Events Committees and provides physician device training for Stryker Neurovascular and Covidien-ev3. These are minor financial conflicts by CNS guidelines. Dr Khalessi further serves on the AHA Writing Group for Extended Use of iv-tPA on behalf of the AANS and the National Steering Committee for Stroke Outcomes for the University Healthcare Consortium (UHC). These Committee assignments are potential related fiduciary but not financial conflicts. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Alexander A. Khalessi San Diego, California Kyle M. Fargen Gainesville, Florida Sean Lavine New York, New York J. Mocco Nashville, Tennessee 1. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368(10):893-903. 2. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914-923. 3. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-913. 4. Brown D. Long-awaited stroke studies show hopeful new treatment no better than older one. The Washington Post. February 8, 2013. 5. Ciccone A. 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Alfonso Ciccone, Carlo Poma Hosp, Mantua, Italy; Luca Valvassori, Boccardi, 2013 Edoardo Boccardi, Roberto Sterzi for SYNTHESIS Investigators “Synthesis Expansion: randomized trial on Primary endovascular treatment vs standard intravenous recombinant tissue plasminogen activator for acute ischemic stroke”, Niguarda Ca’ Granda Hosp, Milan, Italy; Presented at the International Stroke Conference 2013, February 6, 2013, Honolulu, Hawaii. 13. Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: a doubling of treatment rates over the course of 5 years. Stroke. 2011;42(7):1952-1955. 14. Morgenstern LB, Staub L, Chan W, et al. Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project. Stroke. 2002;33(1):160-166. 15. de Los Ríos la Rosa F, Khoury J, Kissela BM, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: the effect of the European Cooperative Acute Stroke Study (ECASS) III Trial. Stroke. 2012;43(6):1591-1595. 16. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007;38(3):967-973. 17. Fargen KM, Meyers PM, Khatri P, Mocco J. Improvements in recanalization with modern stroke therapy: a review of prospective ischemic stroke trials during the last two decades [published online ahead of print]. J Neurointerv Surg. 2012. 10.1227/01.neu.0000430514.46473.4f Preliminary Results of the ARUBA Study Arteriovenous malformations (AVMs) are congenital lesions that, when left untreated, portend a lifelong cumulative risk of stroke and death. The fact that eradicating an AVM to eliminate its natural risk comes at a price to the patient is not news and does not warrant investigation. What is worthy of scrutiny is the need to value and scale this induced morbidity in the light of the gain achieved, ie: a life with long lasting cure. ARUBA tells us what we already know: there is an initial price attached to the intervention. It does not tell us whether the price is too high for any specific AVM. Yet, in spite of the grave methodological shortcomings of the trial that highly bias its results from the outset against intervention, intervention still emerged a superior option for the Spetzler-Martin Grade 1 AVM. The message is clear. There never was clinical equipoise to justify randomizing grade 1, and almost certainly grade 2 patients. Equally, there never was equipoise for the enrolled grade 4 patients, who should be, by and large, left untreated. A registry of at least all unselected grade 3 patients is what is needed to evoke meaningful data that can preserve external validity. On May 10, 2013, the National Institute of Neurological Disorders and Stroke (NINDS) announced that A Randomized Trial of Unruptured Brain AVMs study (ARUBA) had prematurely stopped enrollment—a result of the pre-planned interim analysis performed by the trial’s independent Data and Safety Monitoring Board (DSMB), which demonstrated an event rate three times higher in the intervention group than in the medical management group. 1 ARUBA was a randomized, multi-center trial comparing “best possible AVM eradication” with non-invasive, medical management to the primary endpoint, a composite of symptomatic stroke or death. Methods to eradicate brain arteriovenous malformations (BAVM) included radiosurgery, microsurgical resection, and endo- vascular embolization, alone or in combination. The secondary outcome measure was disability as measured by the Rankin Score at 5 years post-randomization. The initial study design had called for enrollment of 800 patients, but this number was later reduced to 400 CORRESPONDENCE NEUROSURGERY VOLUME 73 | NUMBER 2 | AUGUST 2013 | E379 . Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.