Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, United States.
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, United States.
J Clin Neurosci. 2021 Dec;94:209-215. doi: 10.1016/j.jocn.2021.10.036. Epub 2021 Nov 5.
The role of microsurgery and radiosurgery in the management of low-grade (Spetzler-Martin grade 1 and 2) arteriovenous malformations (AVMs) remains controversial. We aimed to compare outcomes of low-grade AVMs following microsurgery and radiosurgery using a database of AVM patients presenting between 1990 and 2017. Procedure-related complications, obliteration, and functional status at last follow-up were compared between groups. Hemorrhage-free survival was compared using Kaplan-Meier analysis with subgroup analyses by rupture status on presentation. The study involved 233 patients, of which 113 and 120 were treated with microsurgery and radiosurgery, respectively. The complication rates were statistically comparable between both treatment modalities. Mean follow-up time was 5.1 ± 5.2 years. In the complete cohort, there was no significant difference in hemorrhage-free survival between microsurgery and radiosurgery (log-rank p = 0.676, Breslow p = 0.493). When excluding procedure-related hemorrhage and partial resection, hemorrhage-free survival was significantly higher in the surgically treated cohort (log-rank = 0.094, Breslow p = 0.034). The obliteration rate was significantly higher in the surgical cohort (96% vs. 57%, p < 0.001), while functional status was similar. Microsurgery may offer superior hemorrhage-free survival in the early post-treatment period and demonstrates equivalent long-term hemorrhage control and functional outcome at 5 years compared to radiosurgery with nearly complete obliteration rates. Persistent neurologic deficits following microsurgery and symptomatic cerebral edema represent important treatment risks despite low SM grading. Appropriate patient selection even when dealing with low-grade AVMs is advised, as judicious patient selection and emphasis on technical success can minimize procedure-related hemorrhage and the incidence of subtotal resection.
显微手术和放射外科治疗低级别（Spetzler-Martin 分级 1 和 2）动静脉畸形（AVM）的作用仍存在争议。我们旨在通过比较 1990 年至 2017 年间就诊的 AVM 患者数据库，比较显微手术和放射外科治疗低级别 AVM 的结果。比较两组之间的手术相关并发症、闭塞和最后随访时的功能状态。使用 Kaplan-Meier 分析并根据就诊时破裂状态进行亚组分析，比较无出血生存率。该研究涉及 233 例患者，其中 113 例和 120 例分别接受了显微手术和放射外科治疗。两种治疗方法的并发症发生率无统计学差异。平均随访时间为 5.1±5.2 年。在全队列中，显微手术和放射外科治疗的无出血生存率无显著差异（对数秩检验 p=0.676，Breslow p=0.493）。当排除与手术相关的出血和部分切除时，手术治疗组的无出血生存率显著较高（对数秩检验 p=0.094，Breslow p=0.034）。手术组的闭塞率明显较高（96%比 57%，p<0.001），而功能状态相似。显微手术可能在治疗后早期提供更高的无出血生存率，并在 5 年时显示出与放射外科相当的长期出血控制和功能结局，达到近乎完全闭塞率。尽管 SM 分级较低，但显微手术后持续存在的神经功能缺损和症状性脑水肿是重要的治疗风险。即使处理低级别 AVM，也建议进行适当的患者选择，因为明智的患者选择和强调技术成功可以最大限度地减少手术相关出血和次全切除的发生率。
