1Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford.
2Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research (BMIR), Stanford.
J Neurosurg. 2021 Jun 11;136(1):185-196. doi: 10.3171/2020.9.JNS201538. Print 2022 Jan 1.
OBJECTIVE: Microsurgical resection of arteriovenous malformations (AVMs) can be aided by staged treatment consisting of stereotactic radiosurgery followed by resection in a delayed fashion. This approach is particularly useful for high Spetzler-Martin (SM) grade lesions because radiosurgery can reduce flow through the AVM, downgrade the SM rating, and induce histopathological changes that additively render the AVM more manageable for resection. The authors present their 28-year experience in managing AVMs with adjunctive radiosurgery followed by resection. METHODS: The authors retrospectively reviewed records of patients treated for cerebral AVMs at their institution between January 1990 and August 2019. All patients who underwent stereotactic radiosurgery (with or without embolization), followed by resection, were included in the study. Of 1245 patients, 95 met the eligibility criteria. Univariate and multivariate regression analyses were performed to assess relationships between key variables and clinical outcomes. RESULTS: The majority of lesions treated (53.9%) were high grade (SM grade IV-V), 31.5% were intermediate (SM grade III), and 16.6% were low grade (SM grade I-II). Hemorrhage was the initial presenting sign in half of all patients (49.5%). Complete resection was achieved among 84% of patients, whereas 16% had partial resection, the majority of whom received additional radiosurgery. Modified Rankin Scale (mRS) scores of 0-2 were achieved in 79.8% of patients, and 20.2% had poor (mRS scores 3-6) outcomes. Improved (44.8%) or stable (19%) mRS scores were observed among 63.8% of patients, whereas 36.2% had a decline in mRS scores. This includes 22 patients (23.4%) with AVM hemorrhage and 6 deaths (6.7%) outside the perioperative period but prior to AVM obliteration. CONCLUSIONS: Stereotactic radiosurgery is a useful adjunct in the presurgical management of cerebral AVMs. Multimodal therapy allowed for high rates of AVM obliteration and acceptable morbidity rates, despite the predominance of high-grade lesions in this series of patients.
目的：动静脉畸形（AVM）的显微切除可以通过分期治疗来辅助，包括立体定向放射外科治疗，然后延迟切除。这种方法对于高斯皮策-马丁（SM）分级病变特别有用，因为放射外科可以减少 AVM 的血流，降低 SM 评分，并诱导组织病理学改变，使 AVM 更易于切除。作者介绍了他们 28 年来在辅助放射外科治疗后切除 AVM 的经验。
方法：作者回顾性分析了 1990 年 1 月至 2019 年 8 月期间在其机构接受脑 AVM 治疗的患者记录。所有接受立体定向放射外科（伴或不伴栓塞）治疗，然后切除的患者均纳入本研究。在 1245 名患者中，有 95 名符合入选标准。采用单变量和多变量回归分析评估关键变量与临床结果之间的关系。
结果：治疗的大多数病变（53.9%）为高级别（SM 分级 IV-V），31.5%为中级别（SM 分级 III），16.6%为低级别（SM 分级 I-II）。半数患者（49.5%）的初始表现为出血。84%的患者实现了完全切除，而 16%的患者进行了部分切除，其中大多数患者接受了额外的放射外科治疗。79.8%的患者获得了改良 Rankin 量表（mRS）评分 0-2，20.2%的患者预后较差（mRS 评分 3-6）。63.8%的患者 mRS 评分改善（44.8%）或稳定（19%），36.2%的患者 mRS 评分下降。这包括 22 名（23.4%）有 AVM 出血的患者和 6 名（6.7%）在围手术期以外但在 AVM 闭塞前死亡的患者。
结论：立体定向放射外科是脑 AVM 术前治疗的有用辅助手段。尽管本系列患者中高级别病变占主导地位，但多模式治疗可实现高 AVM 闭塞率和可接受的发病率。
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