基于补充的斯德哥尔摩-马丁分级系统对中高级动静脉畸形行立体定向放射外科治疗：按分级分层的结果。

Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system.

机构信息

1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and.

出版信息

J Neurosurg. 2022 Jul 8;138(3):804-809. doi: 10.3171/2022.5.JNS22761. Print 2023 Mar 1.

DOI:10.3171/2022.5.JNS22761

PMID:35901695

Abstract

OBJECTIVE

The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV-V) AVMs to enable comparison with published microsurgical series.

METHODS

In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV-V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV-V AVMs.

RESULTS

AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38).

CONCLUSIONS

The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of "inoperable" AVMs according to Supp-SM grade (≥ 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.

摘要

目的

补充后的斯佩茨勒-马丁（Supp-SM）分级系统旨在提高脑动静脉畸形（AVM）患者手术风险的预测准确性。本研究的目的是将 Supp-SM 分级系统应用于接受立体定向放射外科（SRS）治疗斯佩茨勒-马丁（SM）中等级（III 级）或高等级（IV-V 级）AVM 的患者，以便与已发表的显微外科系列进行比较。

方法

在 1990 年至 2016 年间接受 SRS 治疗的 219 名患者中，计算了 SM 级 III（n = 154）或 SM 级 IV-V（n = 65）AVM 的 Supp-SM 级。这些患者的 Supp-SM 分级为 4 级（n = 14，6%）、5 级（n = 36，16%）、6 级（n = 67，31%）、7 级（n = 76，35%）和 8-9 级（n = 26，12%）。60 名患者（27%）有深部 AVM（基底节、丘脑或脑干）。39 名患者（18%）进行了体积分期 SRS；41 名患者（19%）接受了重复 SRS。SM 级 III AVM 的中位随访时间为 69 个月，SM 级 IV-V AVM 为 113 个月。

结果

在初始 SRS 后中位数为 38 个月时，163 名患者（74%）确认了 AVM 闭塞。4 年和 8 年的闭塞率分别为 59%和 76%。31 名患者（14%）因出血（n = 7，3%）或放射损伤（n = 24，11%）而出现 SRS 后缺陷。6 名患者（3%）在 SRS 后死亡（出血，n = 5；放射损伤，n = 1）。4 年和 8 年时神经功能下降或死亡的发生率分别为 11%和 18%。非闭塞的预测因素为深部位置（HR 0.57，95%CI 0.39-0.82，p = 0.003）和 AVM 体积增加（HR 0.96，95%CI 0.93-0.99，p = 0.002）。AVM 体积增加是唯一与神经功能下降相关的因素（HR 1.05，95%CI 1.02-1.08，p = 0.002）。Supp-SM 分级评分与闭塞（HR 0.94，95%CI 0.82-1.09，p = 0.43）或神经功能下降（HR 1.15，95%CI 0.84-1.56，p = 0.38）均无相关性。