Sattari Shahab Aldin, Shahbandi Ataollah, Kim Jennifer E, Lee Ryan P, Feghali James, Hung Alice, Yang Wuyang, Rincon-Torroella Jordina, Xu Risheng, Caplan Justin M, Gonzalez L Fernando, Tamargo Rafael J, Huang Judy
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA.
Tehran School of Medicine, Tehran University of Medical Science, Tehran , Iran.
Neurosurgery. 2023 Sep 1;93(3):510-523. doi: 10.1227/neu.0000000000002460. Epub 2023 Mar 31.
Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial.
To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs.
Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence.
Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups.
Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients.
对于脑动静脉畸形（bAVM）采用显微手术或立体定向放射外科治疗（SRS）的治疗决策存在争议。
进行一项系统评价和荟萃分析，比较bAVM的显微手术与SRS。
检索Medline和PubMed自创建至2022年6月21日的数据。主要结局为闭塞和随访期出血，次要结局为永久性神经功能缺损、改良Rankin量表（mRS）恶化、随访时mRS>2以及死亡率。采用GRADE方法对证据水平进行分级。
纳入8项研究，共817例患者，其中分别有432例（52.8%）和385例（47.1%）患者接受了显微手术和SRS。两组在年龄、性别、Spetzler-Martin分级、病灶大小、位置、深部静脉引流、功能区以及随访方面具有可比性。在显微手术组中，闭塞的优势比（OR）更高（OR = 18.51 [11.05, 31.01]，P <.000001，证据：高），随访期出血的风险比更低（风险比 = 0.47 [0.23, 0.97]，P =.04，证据：中等）。显微手术导致永久性神经功能缺损的OR更高（OR = 2.85 [1.63, 4.97]，P =.0002，证据：低），而两组间mRS恶化（OR = 1.24 [0.65, 2.38]，P =.52，证据：中等）、随访时mRS>2（OR = 0.78 [0.36, 1.7]，P =.53，证据：中等）以及死亡率（OR = 1.17 [0.41, 3.3]，P =.77，证据：中等）相当。
显微手术在闭塞bAVM和预防进一步出血方面更具优势。尽管显微手术术后神经功能缺损发生率较高，但功能状态和死亡率与接受SRS的患者相当。对于bAVM，显微手术应仍是一线治疗选择，SRS则适用于难以到达的部位、功能区以及医学上高风险或不愿意接受手术的患者。
