Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.
Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada.
Neurosurgery. 2020 Sep 1;87(3):442-452. doi: 10.1093/neuros/nyaa004.
No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs).
To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and "excellent" outcomes (defined as total obliteration without new post-SRS deficit).
Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs.
The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
目前尚无关于 Spetzler-Martin 分级 I 和 II 动静脉畸形（AVM）的立体定向放射外科（SRS）管理指南。
根据系统文献回顾，为 I-II 级 AVM 制定 SRS 实践指南。
对 Medline、Embase 和 Scopus 进行符合 Preferred Reporting Items for Systematic Reviews and Meta-Analyses（PRISMA）的检索，检索时间为 1986 年至 2018 年，以查找报道 SRS 后随访时间≥24 个月且≥10 例 I-II 级 AVM 患者的 SRS 结果的文献。主要终点是闭塞和出血；次要终点包括 Spetzler-Martin 参数、剂量学变量和“优秀”结果（定义为无新 SRS 后缺损的完全闭塞）。
从 447 篇摘要中筛选出 8 篇文献（n=1，2 级证据；n=7，4 级证据），共纳入 1102 例 AVM，其中 836 例（76%）为 II 级。在中位数为 37 个月时，884 例（80%）实现了闭塞；在中位数为 68 个月的随访期间，发生了 66 例出血（6%）。78%的患者实现了无出血的完全闭塞。在 836 例 II 级 AVM 中，有 680 例报告了 Spetzler-Martin 参数：377 例为功能区脑，178 例有深部静脉引流，总计 680 例中有 555 例（82%）为高危 SRS 治疗的 II 级 AVM。
关于 I-II 级 AVM 的 SRS 文献质量较低，限制了对其的解释。谨慎地说，我们观察到 SRS 似乎是一种安全、有效的 I-II 级 AVM 治疗方法，可作为一线治疗方法，特别是对于深部或功能区病变。之前的出版物可能受到选择偏倚的影响，即切除了病情有利的 AVM，而那些并发症和非闭塞风险较高的 AVM 则不成比例地转介进行 SRS。
