Tos Salem M, Osama Mahmoud, Mantziaris Georgios, Hajikarimloo Bardia, Adeeb Nimer, Kandregula Sandeep, Salim Hamza Adel, Musmar Basel, Ogilvy Christopher S, Kondziolka Douglas, Dmytriw Adam A, Naamani Kareem El, Abdelsalam Ahmed, Kumbhare Deepak, Gummadi Sanjeev, Ataoglu Cagdas, Essibayi Muhammed Amir, Erginoglu Ufuk, Keles Abdullah, Muram Sandeep, Sconzo Daniel, Riina Howard, Rezai Arwin, Pöppe Johannes, Sen Rajeev D, Kim Louis J, Alwakaa Omar, Griessenauer Christoph J, Jabbour Pascal, Tjoumakaris Stavropoula I, Burkhardt Jan-Karl, Starke Robert M, Baskaya Mustafa K, Sekhar Laligam N, Levitt Michael R, Altschul David J, Haranhalli Neil, McAvoy Malia, Abushehab Abdallah, Aslan Assala, Swaid Christian, Abla Adib, Stapleton Christopher, Koch Matthew, Srinivasan Visish M, Chen Peng R, Blackburn Spiros, Choudhri Omar, Pukenas Bryan, Orbach Darren, Smith Edward, Möhlenbruch Markus, Alaraj Ali, Aziz-Sultan Ali, Patel Aman B, Savardekar Amey, Cuellar Hugo H, Dlouhy Kathleen, El Ahmadieh Tarek, Lawton Michael, Siddiqui Adnan, Morcos Jacques, Guthikonda Bharat, Sheehan Jason
Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA.
Neurosurg Rev. 2025 Mar 31;48(1):337. doi: 10.1007/s10143-025-03465-6.
Spetzler-Martin Grade IV arteriovenous malformations (AVMs) are challenging due to high risks associated with both treatment and natural progression. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) in high-grade AVMs, analyzing obliteration rates, complications, and functional outcomes. A retrospective cohort of 96 patients treated with either microsurgical resection (33 patients) or SRS (63 patients) was analyzed. Propensity-score matching was employed to account for baseline variables such as AVM size (cm), preoperative embolization and rupture status. Primary endpoints included AVM obliteration, complication rates, and modified Rankin Scale (mRS) scores. After matching, 31 patients per group were analyzed. Microsurgical resection achieved significantly higher obliteration rates (87.1%) compared to SRS (32.3%, p < 0.001). In the matched SRS cohort (n = 31), the actuarial obliteration rates were 11% (95% CI: 0-22%) at 1 year, 17% (95% CI: 0-31%) at 3 years, and 43% (95% CI: 13-63%) at 5 years post-treatment. Complication rates were similar (32.3% resection, 38.7% SRS, p = 0.6). Functional outcomes in terms of improvement in modified Rankin Scale (mRS) scores were observed in 50.0% of microsurgery patients and 41.4% of SRS patients. However, the absolute number of patients improving was similar (13 vs. 12), and the microsurgery group had more cases of worsening mRS scores compared to the SRS group (4 vs. 2). The difference was not statistically significant (p = 0.4). Microsurgical resection offers superior obliteration rates for high-grade AVMs with comparable complication risks to SRS. SRS remains a valuable alternative for select patients, particularly those ineligible for resection. Future research should focus on optimizing multimodal treatment approaches. Clinical trial number Not applicable.
斯佩茨勒-马丁四级动静脉畸形（AVM）因治疗和自然进展都存在高风险而具有挑战性。本研究比较了高级别AVM的显微手术切除和立体定向放射外科治疗（SRS）的结果，分析了闭塞率、并发症和功能结局。对96例接受显微手术切除（33例患者）或SRS（63例患者）治疗的患者进行回顾性队列分析。采用倾向得分匹配法来考虑基线变量，如AVM大小（厘米）、术前栓塞和破裂状态。主要终点包括AVM闭塞、并发症发生率和改良Rankin量表（mRS）评分。匹配后，每组分析31例患者。与SRS（32.3%，p < 0.001）相比，显微手术切除的闭塞率显著更高（87.1%）。在匹配的SRS队列（n = 31）中，治疗后1年的精算闭塞率为11%（95%CI：0 - 22%），3年为17%（95%CI：0 - 31%），5年为43%（95%CI：13 - 63%）。并发症发生率相似（切除组为32.3%，SRS组为38.7%，p = 0.6）。在显微手术患者中，50.0%的患者改良Rankin量表（mRS）评分有所改善，SRS患者中这一比例为41.4%。然而，改善的患者绝对数量相似（13例对12例），与SRS组相比，显微手术组mRS评分恶化的病例更多（4例对2例）。差异无统计学意义（p = 0.4）。对于高级别AVM，显微手术切除提供了更高的闭塞率，且并发症风险与SRS相当。SRS仍然是部分患者的有价值选择，特别是那些不适合切除的患者。未来的研究应专注于优化多模式治疗方法。临床试验编号：不适用。
