Spetzler-Martin Grade Research Articles

Effectiveness of super-selective digital subtraction angiography and 3D rotational digital subtraction venography for a developmental venous anomaly with an arteriovenous malformation: A case report and literature review

Background: Arteriovenous malformation (AVM) and developmental venous anomaly (DVA) rarely coexist. Developing a surgical strategy to treat this co-occurrence is difficult due to the unclear pathogenesis. We report the use of super-selective digital subtraction angiography (DSA) and Three-dimensional (3D) rotational digital subtraction venography (DSV) to develop a surgical strategy for complex AVM draining into a DVA. Case Description: A 58-year-old woman presented with left hemiparesis and unconsciousness. Plain and contrast computed tomography showed a right frontal subcortical hematoma and a heterogeneous contrast lesion anterior to the hematoma, leading to a dilated vessel. The hematoma was removed due to worsening unconsciousness. DSA revealed a right frontal AVM of Spetzler-Martin grade 2 with superficial drainage into a DVA, and 3D-DSV revealed that the intermediate part of the DVA involved normal parenchyma. Interventional transarterial embolization and surgical nidus removal were planned. Preoperative super-selective DSA showed two medullary veins draining from the AVM into the DVA. Thus, we decided to separate the two medullary veins from the nidus. Postoperative angiography revealed complete removal of the AVM and preservation of the DVA. Conclusion: Treating a complex AVM draining into a DVA is challenging; surgeons have to remove only the AVM portion and preserve the DVA. Super-selective DSA and 3D rotational DSV were performed to develop the surgical strategy.

DECISION MAKING IN EPILEPTIC AVMS

While there is no doubt about the need for surgical treatment of a ruptured arteriovenous malformation (AVM), the decision to surgically treat a patient presenting solely with seizures is more controversial. Arteriovenous malformations (AVMs) arise from an abnormal connection between high-flow arterial vessels and low-flow venous vessels, resulting in a dysplastic vascular nidus within the brain tissue. The inherent flow irregularities within AVMs make them prone to rupture, which occurs in approximately half of patients. Additionally, seizures represent the second most common clinical manifestation of AVMs, presenting in 20%–45% of individuals with these lesions. This paper investigates the angiographic and MRI features of arteriovenous malformations that present with epilepsy, and discusses the surgical considerations in managing these patients and integration of multimodal approach focusing on the standard microsurgical techniques utilized. Patients presenting with seizures as the primary symptom of an arteriovenous malformation carry a higher surgical risk compared to those presenting with haemorrhage. Several factors have been associated with an increased risk of seizures in patients with arteriovenous malformations (AVMs). These include male gender, younger patient age, AVMs located in the frontal or temporal lobes, AVMs situated in the brain cortex, superficial venous drainage, a superficial temporal lobe AVM nidus, fistulous AVMs, and AVMs with venous stenosis. Surgical treatment is the recommended approach for patients with Spetzler-Martin grade I–III arteriovenous malformations. Resecting an unruptured brain arteriovenous malformation in a patient presenting only with epilepsy is a complex decision that requires a thorough understanding of the lesion’s anatomy, the patient’s history, and the neurosurgeon’s skills.

Clinical Presentations and Treatment Approaches in a Retrospective Analysis of 128 Intracranial Arteriovenous Malformation Cases

Background: Intracranial AVMs are a highly heterogeneous group of lesions that, while not very common, can pose significant risks. The therapeutic management of AVMs is complicated by ambiguous guidelines, particularly regarding which Spetzler–Martin grades should dictate specific treatment options. This study analyzed the clinical presentations and treatment approaches of 128 brain AVM cases managed between 2014 and 2022 at the National Institute of Neurology and Neurovascular Diseases in Bucharest, Romania. Methods: A retrospective analysis was conducted on patient demographics, clinical symptoms, Spetzler–Martin categorization, nidus localization, therapeutic management, and outcomes. Statistical analysis was performed using Python 3.10. Results: In our cohort of patients, the median age was 45 years, with a slight male predominance (67 males, 61 females). At admission, 51.5% presented with elevated blood pressure. The majority of patients had a Spetzler–Martin score of 2 (37.5%), followed by scores of 3 (31.3%) and 1 (20.3%). Treatment strategies included microsurgical resection in 32% of cases, conservative management in 31.2%, Gamma Knife radiosurgery in 22.6%, and endovascular embolization in 13.3%. Notably, open surgery was predominantly chosen for Grade II AVMs. The functional outcomes were favorable, with 69.5% achieving a good recovery score on the Glasgow Outcome Scale. Only four in-hospital deaths occurred, all in patients who underwent open surgery, and no deaths were recorded during the two-year follow-up. Conclusions: AVMs within the same Spetzler–Martin grade display considerable complexity, necessitating personalized treatment strategies. Our findings highlight the limitations of open surgery for Grade I cases but affirm its effectiveness for Grade II AVMs.

The Correlation of Vessel Wall Macrophage Infiltration with Hemosiderin in Arteriovenous Malformations

Endothelial dysfunction, induced by high shear stress from increased nidal blood flow, may promote a cycle of inflammation, possibly leading to instability and cerebral arteriovenous malformations (AVMs) rupture. Macrophages, identified with CD68, are key inflammatory components in AVM pathology. We aim to evaluate the relationship of inflammation with AVM flow and hemosiderin. This is a retrospective study of archived tissue. Adult patients (2002-2022) with baseline quantitative magnetic resonance angiography (QMRA) imaging, no embolization, and history of microsurgical resection (n=17), with both ruptured (n=9) and unruptured cases (n=8). Brain AVM sections were stained with CD68 to quantify vessel wall macrophage infiltration and hematoxylin and eosin stain as a control and to quantify hemosiderin. QMRA with noninvasive optimal vessel analysis (NOVA) was reviewed, and AVM flow was calculated. Statistical analyses were performed. There were no significant differences between macrophage infiltration and patient demographics, Spetzler-Martin grade, eloquence, venous stenosis, nidus compactness, volume, and AVM flow. Vessel wall macrophage infiltration positively correlated with patients who presented with confirmed AVM rupture (163.8 +/- 46.7 vs. 101.3 +/- 49.4, p=0.017). Increases in vessel wall macrophage infiltration were found to positively correlate with higher grades of hemosiderin (p=0.023), except for grade 4 hemosiderin. Venous anomaly showed a negative association with macrophage infiltration (p=0.035). These findings suggest a relationship between AVM vessel wall inflammation, hemosiderin, and hemorrhage presentation. Further investigations with larger sample sizes are warranted to understand the role of altered hemodynamics, hemosiderin deposition and inflammation in AVM vessel walls.

Comparing stand-alone endovascular embolization versus stereotactic radiosurgery in the treatment of arteriovenous malformations with Spetzler-Martin grades I–III: a propensity score matched study

BackgroundArteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable...

Conservative management of brain arteriovenous malformations: results of the prospective observation registry of a pragmatic trial.

Many patients recruited in the Treatment of Brain Arteriovenous Malformations Study (TOBAS) are managed conservatively. The aim of this study was to monitor what happened to those patients. TOBAS comprises two randomized controlled trials and multiple prospective registries. All patients with brain arteriovenous malformations (AVMs) can participate. This report concerns patients selected for conservative management. The primary trial outcome measure is related death or dependency (modified Rankin Scale [mRS] score > 2) at 10 years. Secondary outcomes include intracranial hemorrhages, nonhemorrhagic neurological events, and serious adverse events (SAEs). For this report, outcome results are presented using patient-years, Kaplan-Meier survival curves, and Cox log-rank tests. There was no blinding. From June 2014 to May 2021, 1010 patients were recruited, of whom 498 (49%) were proposed the prospective observation registry. After exclusions, 434 (87%) patients remained for analysis. The majority of patients had unruptured AVMs (378/434 [87%]), of which 195 (52%) were low grade (Spetzler-Martin grade I or II). During a mean follow-up period of 3.2 years (total 1368 patient-years), the primary outcome occurred in 23 of 434 (5%) patients, corresponding to an incidence of 1.7 (95% CI 1.1-2.5) per 100 patient-years. For unruptured AVMs the incidence was 1.1 (95% CI 0.7-1.9) per 100 patient-years, and for low-grade unruptured AVMs it was 0.6 (95% CI 0.2-1.7) per 100 patient-years. Poor outcomes were more frequent in patients with a history of rupture (HR 5.6 [95% CI 2.4-13.0], p < 0.001), infratentorial AVMs (HR 2.9 [95% CI 1.1-7.3], p = 0.027), and age ≥ 55 years (HR 3.2 [95% CI 1.4-7.6], p = 0.007). Major intracranial hemorrhage occurred in 35 of 434 (8%) patients (incidence of 2.6 [95% CI 1.9-3.6] per 100 patient-years; 2.0 [95% CI 1.3-2.9] per 100 patient-years for unruptured AVMs and 1.3 [95% CI 0.6-2.6] per 100 patient-years for low-grade unruptured AVMs). Major AVM hemorrhages were more frequent in ruptured (HR 4.4 [95% CI 2.1-8.9], p < 0.001), large (HR 2.6 [95% CI 1.1-6.6], p = 0.039), and high-grade (HR 2.5 [95% CI 1.2-5.3], p = 0.013) AVMs and those with deep venous drainage (HR 2.1 [95% CI 1.1-4.2], p = 0.032). SAEs occurred in 48 of 434 (11%) patients (incidence of 3.6 [95% CI 2.7-4.8] per 100 patient-years). For unruptured AVMs the incidence was 2.8 (95% CI 2.0-4.0) per 100 patient-years, and for low-grade unruptured AVMs it was 1.8 (95% CI 1.0-3.2) per 100 patient-years. Nearly half of TOBAS participants were observed. Rates of untoward neurological events were within expected boundaries.

Natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations.

The natural history of ruptured high Spetzler-Martin grade IV and V brain arteriovenous malformations (bAVMs) is underreported given the scarcity of this pathology, and decision-making for patients with bAVMs remains unclarified. In this study, the authors sought to shed light on this topic. Patients harboring ruptured high-grade bAVMs were identified from an institutional database spanning from 1990 to 2020. The authors examined outcomes of annual hemorrhagic risk in natural history and after treatment, follow-up hemorrhage rate, bAVM obliteration, follow-up modified Rankin Scale (mRS) score > 2, worsened mRS score, and mortality. After reviewing the charts of 1066 patients without hereditary hemorrhagic telangiectasia, 84 patients with ruptured high-grade bAVMs were included in the study for analysis. For cortical bAVMs, the annual risk of hemorrhage during natural history was 2.68%. Surgery decreased the risk to 0.74%, while radiosurgery increased the risk to 5.35%, and embolization only increased the risk to 16.96%. For deep-seated high-grade bAVMs, the annual risk of hemorrhage during natural history was 8.37%. Radiosurgery decreased the risk to 3.11%, surgery decreased the risk to 5.25%, and embolization only increased the risk to 22.33%. Poisson regression analysis demonstrated that embolization only increased the risk of hemorrhage in cortical bAVMs (rate ratio 4.745, 95% CI 1.365-12.819; p = 0.005) and deep-seated bAVMs (rate ratio 6.290, 95% CI 0.997-21.932; p = 0.013). Logistic regression analysis showed that surgery (OR 52.000, 95% CI 8.083-1046.127; p = 0.004) and radiosurgery (OR 11.142, 95% CI 1.804-217.650; p = 0.029) were predictors of obliteration in cortical and deep-seated bAVMs, respectively. The proportions of patients experiencing a worsened mRS score, a follow-up mRS score > 2, and mortality were similar between conservative and treatment groups. The natural history of cortical ruptured high-grade bAVMs bears a risk similar to that of incidental bAVMs, whereas deep-seated ruptured high-grade bAVMs have an increased risk of hemorrhage. With extremely prudent patient selection, surgery might be a viable option for cortical bAVMs to obliterate the bAVM and reduce hemorrhagic risk, while preserving functional status. Radiosurgery might be beneficial to lower hemorrhagic risk in deep-seated bAVMs. Embolization as a single modality should be avoided as it provides no benefit to reduce hemorrhagic risk.

STUDY OF SOMATIC AND GERMINAL MUTATIONS IN ARTERIOVENOUS MALFORMATIONS OF THE BRAIN USING WHOLE EXOME SEQUENCING

Rare vascular lesions known as brain arteriovenous malformations (bAVMs) are caused by shunts between cerebral arteries and veins that do not involve the capillary bed. The majority of bAVMs do not cause any symptoms, however some can be controlled by seizures and result in potentially fatal brain hemorrhages. Over the past ten years, significant advancements in our understanding of bAVM pathogenesis have been accomplished, primarily through the use of genome sequencing and biomolecular analysis. An autosomal dominant vascular disorder called Hereditary Hemorrhagic Telangiectasia (HHT, also known as Rendu-Osler-Weber Syndrome) affects about 1 in 5000 people globally and is associated with about 5% of brain AVMs, while the remaining 95% are due to sporadic mutations. The major aim of the project is to investigate genetic causes of sporadic forms of AVMs in the brain by means of whole-exome sequencing of tissues with AVM lesions and blood samples. Analysis of somatic mutations will broaden the understanding of AVM pathogenesis. This study was carried out in accordance with the Declaration of Helsinki's tenets and approved by the National Center of Biotechnology 's ethics committee (№9, 7 November 2023, ) Astana). Based on clinical data, the age range of the patients at the onset of the disease also encompassed 25 to 40 years. To confirm the diagnosis, MRI and CAG data were used to validate the diagnosis. Each patient completed a specially designed questionnaire with medical information (such as age of debut and type of course) and demographic data (such as age, gender, and nationality). Three patients were classified as having a Spetzler-Martin grade II, while one patient was categorized as grade III. The sizes of arteriovenous malformations (AVMs) varied from 0 to 3 mm in one patient (grade II) to 3 to 6 mm in three patients (grades II-III). AVM tissue specimens were obtained during clinically necessary procedures. Brain AVM tissues were collected during surgery, which involved trepanation and excision of the AVM. Blood samples were also collected from these patients. Both DNA and RNA were isolated from these tissue and blood samples for subsequent exome sequencing an. Qubit 2.0 fluorometer was employed for more precise determination of DNA concentration, given that the nucleic acids will be utilized in future whole exome sequencing analysis. Whole exome sequencing was performed on six samples (blood and tissue) by Novaseq 6000 (Illumina). The annotated results were analyzed for the presence of single-nucleotide polymorphisms (SNP) and insertion-deletion mutations (Indels) between DNAs from the AVM tissue sample and blood. The GATK workflow was used for the analysis and annotation of the raw data, and vcf files were generated. Then, the variants were filtered for a quality ≥ 30 in Excel 1st blood 117554, 1st tissue 114715; 2nd blood 112972, 2nd tissue 116022; 3rd blood 112859, 3rd tissue 117168 and genotype differences between tissue and blood DNA samples 1st blood 114512, 1st tissue 111682; 2nd blood 110614, 2nd tissue 111982; 3rd blood 110564, 3rd tissue 112805. After selecting only non-synonymous, frameshift insertions and deletions variants with different genotypes in the blood and tissue samples, 1st blood 279, 1st tissue 277; 2nd blood 279, 2nd tissue 271; 3rd blood 275, 3rd tissue 268 variations were observed. Analysis of whole-exome data continues.

Diagnostic accuracy of arterial spin labeling MR imaging in detecting cerebral arteriovenous malformations: a systematic review and meta-analysis.

Diagnostic accuracy of arteriovenous malformations (AVMs) is imperative for delineating management. The current standard is digital subtraction angiography (DSA). Arterial spin labeling (ASL) is an understudied noninvasive, non-contrast technique that allows angioarchitecture visualization and additionally quantifies cortical and AVM cerebral blood flow and hemodynamics. This meta-analysis aims to compare ASL and DSA imaging in detecting and characterizing cerebral AVMs. EMBASE, Medline, Scopus, and Cochrane databases were queried from inception to July 2022 for reports of AVMs evaluated by DSA and ASL imaging. Fourteen studies with 278 patients evaluated using DSA and ASL imaging prior to intervention were included; pCASL in 11 studies (n = 239, 85.37%) and PASL in three studies (n = 41, 14.64%). The overall AVM detection rate on ASL was 99% (CI 97-100%); subgroup analysis revealed no difference between pCASL vs. PASL (99%; CI 96-100% vs. 100%; CI 95-100% respectively, p = 0.42). The correlation value comparing ASL and DSA nidus size was 0.99. DSA and ASL intermodality agreement Cohen's k factor for Spetzler Martin Grading (SMG) was reported at a median of 0.98 (IQR 0.73-0.1), with a 1.0 agreement on SMG classification. A median of 25 arteries were detected by DSA (IQR 14.5-27), vs. 25 by ASL (IQR 14.5-27.5) at a median 0.92 k factor. ASL provides angioarchitectural visualization noninferior to DSA and additionally quantifies CBF. Our study suggests that ASL should be considered in the detection of AVMs, especially in patients with contrast contraindications or apprehension towards an invasive assessment.

Influence of preoperative embolisation on resection of brain arteriovenous malformations: cohort study

PurposePreoperative endovascular embolisation is a widely used adjunct for the surgical treatment of brain arteriovenous malformations (AVMs). However, whether this improves completeness of AVM resection is unknown, as previous analyses have not adjusted for potential confounding factors. We aimed to determine if preoperative endovascular embolisation was associated with increased rate of complete AVM resection at first surgery, following adjustment for Spetzler-Martin grade items.MethodsWe identified a cohort of all patients undergoing first ever AVM resection in a specialist neurosciences unit in the NHS Lothian Health Board region of Scotland between June 2004 and June 2022. Data was prospectively extracted from medical records. Our primary outcome was completeness of AVM resection. We determined the odds of complete AVM resection using binomial logistic regression with adjustment for Spetzler-Martin grading system items: maximum nidus diameter, eloquence of adjacent brain and the presence of deep venous drainage.Results88 patients (median age 40y [IQR 19–53], 55% male) underwent AVM resection. 34/88 (39%) patients underwent preoperative embolisation and complete resection was achieved at first surgery in 74/88 (84%). Preoperative embolisation was associated with increased adjusted odds of complete AVM resection (adjusted odds ratio [aOR] 8.6 [95% confidence interval (95% CI) 1.7–67.7]; p = 0.017). The presence of deep venous drainage was associated with reduced chance of complete AVM resection (aOR 0.18 [95% CI 0.04–0.63]; p = 0.009).ConclusionsPreoperative embolisation is associated with improved chances of complete AVM resection following adjustment for Spetzler-Martin grade, and should therefore be considered when planning surgical resection of AVMs.

Timing of diffusion tensor imaging in the management of a ruptured pediatric arteriovenous malformation: illustrative case.

Diffusion tensor imaging (DTI) can characterize eloquent white matter tracts affected by brain arteriovenous malformations (AVMs). However, DTI interpretation can be difficult in ruptured cases due to the presence of blood products. The authors present the case of a ruptured pediatric AVM in the corticospinal tract (CST) and discuss how DTI at different time points informed the treatment. A 9-year-old female presented with a sudden headache and left hemiparesis. She was found to have a Spetzler-Martin grade III, Supplementary grade I AVM in the right caudate and centrum semiovale, with obliteration and corresponding reduced fractional anisotropy (FA), fiber density (FD), and tract count (TC) of the adjacent CST on DTI. The patient remained stable and was scheduled for elective resection following a 6-week period to facilitate hematoma resorption. After 6 weeks, repeat DTI showed part of the nidus within intact CST fibers with concordant improvement in FA, FD, and TC. Considering the nidus location, CST integrity, and motor function recovery, surgery was deferred in favor of stereotactic radiosurgery. In ruptured AVMs, DTI may initially create an incomplete picture and false assumptions about white matter tract integrity. DTI should be repeated if delayed treatment is appropriate to ensure informed decision-making and prevent avoidable permanent neurological deficits. https://thejns.org/doi/10.3171/CASE24225.

Surgical Results with Low-Grade Arteriovenous Malformations : A Single Center 14-Year Experience.

Advancements in AVM surgical techniques for cerebral arteriovenous malformation (AVM) underscore its efficacy. Our research aims to showcase the positive outcomes of treating low-grade AVMs surgically, focusing on safety and effectiveness. We retrospectively reviewed 55 patients (36 males and 19 females; average age 37.4 years) with Spetzler-Martin (S-M) grade 1 and 2 AVMs who underwent surgical resection between January 2009 and December 2022. In our study, 55 patients with S-M grade 1 and 2 AVMs underwent surgical resection, evenly divided between grades 1 (50.9%) and 2 (49.1%). Intracranial hemorrhage was the primary symptom in 74.5% of cases. Pre-operative Glasgow coma scale (GCS) scores revealed 69.1% of patients scored above 13, with 18% below 8. Successful resection was achieved in 87.3%. Postoperatively, 95.5% of ruptured and 90.9% of unruptured AVM patients showed lower or same modified Rankin scale scores. Poorer outcomes were significantly linked to lower GCS scores and intranidal/flow-related aneurysms through multivariate logistic regression. Postoperative seizures noted in nine patients, were exclusive to the ruptured AVM group. Our findings indicate surgical resection as a beneficial treatment for low-grade AVMs, yielding high cure rates and positive functional outcomes in both ruptured and unruptured cases. Preoperative GCS scores and the presence of associated aneurysms are predictive of postoperative functional status. Additionally, managing postoperative seizures effectively is key to enhancing prognosis.

Microsurgery of Cerebral Arteriovenous Malformations in a Resource-Limited Setting: The First Case-Series from Iraq

Cerebral arteriovenous malformations (AVMs) can lead to significant morbidity and are particularly challenging to manage in resource-limited settings where endovascular treatment modalities are unaffordable for most patients. To describe the first case series of AVM from Iraq with an analysis of the related clinicoradiologic characteristics, operative features, and outcomes. A single-center database from October 2018 to December 2022 was reviewed to analyze the characteristics of cerebral AVMs who underwent surgical treatment in Baghdad, Iraq. We collected patient demographics, clinical, radiologic, operative, and the follow-up combined outcome results (modified Rankin Scale score and the presence of AVM remnants). Of the 54 AVM patients treated with microsurgery, the majority of lesions have Spetzler-Martin grade of 3 (31.5%), followed by grade 1 (29.6%). The parietal lobe was the most common location of AVM in 25.9% of the cases, and the temporal location had better outcomes. The mean duration of surgery was 8.5 hours, ranging from 3 to 14 hours, with 20.3% of cases having undergone preoperative stereotactic radiosurgery, and just one patient received preoperative embolization. Good combined outcome (modified Rankin Scale 0-2 and no AVM remnant) was associated with lower SM grades (P=0.003); location in the nondominant hemisphere (P=0.036), and noneloquent regions (P=0.006); absence of deep venous drainage (P=0.042) and no intraoperative brain swelling (P=0.004). The mortality rate in our series was 5.5%. Good clinicoradiologic outcomes can be achieved through microsurgery in a setting where endovascular treatment is inaccessible to patients due to limited resources.

Occipital Interhemispheric Transtentorial Approach for Microsurgical Treatment of Posterior Midbrain Arteriovenous Malformation: 2-Dimensional Operative Video.

Arteriovenous malformations (AVMs) of the brain stem are very rare lesions accounting for 2% to 6% of the cerebral AVMs.1,2 They carry higher risk of hemorrhage3,4 and are associated with poor prognosis.5-7 This is a 27-year-old man who presented with intraventricular hemorrhage, hydrocephalus, and poor neurological status secondary to ruptured AVM. Deep branches from right triplicate superior cerebellar artery, left duplicate superior cerebellar artery, and right posterior cerebral artery were feeding the AVM. The drainage was directly to the vein of Galen. MRI brain showed the location of the AVM in the posterior midbrain area. The AVM was mostly exophytic to brain stem parenchyma which made it favorable for surgical resection.8 After cerebrospinal fluid diversion (initially with external ventricular drain that was then converted to ventriculoperitoneal shunt), the patient showed some neurological improvement over the next weeks. Thus, the decision was made to treat the AVM. The patient underwent preoperative embolization followed by an occipital interhemispheric transtentorial approach. This illustrative video outlines the steps and technical nuances of the right occipital interhemispheric transtentorial approach for microsurgical resection of this Spetzler-Martin grade 3 (S1, E1, V1)/supplementary Spetzler-Martin grade 2 (A2, B0, C0) AVM. Postoperative cerebral angiogram demonstrated no AVM residual. The patient was discharged to a rehabilitation institute and at 3 months of follow-up, he was alert and orientated to time, person, and place without focal deficits. The patient consented to the procedure and to the publication of his image. Institutional Review Board approval was deemed unnecessary.

Stereotactic Radiosurgery for Intermediate (III) or High (IV-V) Spetzler-Martin Grade Arteriovenous Malformations: International Stereotactic Radiosurgery Society Practice Guideline.

Consensus guidelines do not exist to guide the role of stereotactic radiosurgery (SRS) in the management of patients with Spetzler-Martin Grade III-V arteriovenous malformations (AVMs). We sought to establish SRS practice guidelines for Grade III-V AVMs based on a critical systematic review of the published literature. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant search of Medline, Embase, and Scopus, 1986 to 2023, for publications reporting post-SRS outcomes in ≥10 Grade III-V AVMs with the median follow-up ≥24 months was performed. Primary end points were AVM obliteration and post-SRS hemorrhage. Secondary end points included dosimetric variables, Spetzler-Martin parameters, and neurological outcome. : In total, 2463 abstracts were screened, 196 manuscripts were reviewed, and 9 met the strict inclusion criteria. The overall sample of 1634 AVMs consisted of 1431 Grade III (88%), 186 Grade IV (11%), and 11 Grade V lesions (1%). Total median post-SRS follow-up was 53 months for Grade III and 43 months for Grade IV-V AVMs (ranges, 2-290; 12-262). For Grade III AVMs, the crude obliteration rate was 72%, and among Grade IV-V lesions, the crude obliteration rate was 46%. Post-SRS hemorrhage was observed in 7% of Grade III compared with 17% of Grade IV-V lesions. Major permanent deficits or death from hemorrhage or radiation-induced complications occurred in 86 Grade III (6%) and 22 Grade IV-V AVMs (12%). Most patients with Spetzler-Martin Grade III AVMs have favorable SRS treatment outcomes; however, the obliteration rate for Grade IV-V AVMs is less than 50%. The available studies are heterogenous and lack nuanced, long-term, grade-specific outcomes.

Serum Vascular Endothelial Growth Factor and Endostatin as an Adjunct to Clinical Decision Making in Managing Radiation-induced Changes Post Gamma Knife Radiosurgery in Spetzler Martin Grade 3 Arteriovenous Malformations Patients: A Pilot Study

BackgroundRadiation induced changes (RIC) are the most common complications observed post GKRS and may be observed within 6-18months post procedure. It has been observed that almost one third of RICs are symptomatic and half of them are persistent. There is no way to predict which patients will develop these changes and to what extent.This was a prospective analytical pilot study with the aim of understanding the role of Serum Vascular Endothelial Growth Factor and Endostatin as a predictive factor for clinically symptomatic RIC in intracranial AVMs Spetzler Martin (SM) grade 3 being managed with primary Gamma Knife radiosurgery.Total of 15 patients were analysed. 60% of them had a history of bleed. The median volume of AVM Nidus was 4.36 cc. One third of the patients had no imaging changes suggestive of RIC at 1 year follow up and 2 of the patients had symptomatic RIC needing intervention. Before Gamma Knife, the median values of serum concentration of Endostatin and VEGF are 34.98 ng/mL and 168.37 pg/mL respectively . The serum values of VEGF at 1 month post GKRS was much less than the pre GKRS values but not found to be predictive of RIC. No correlation could be observed with the levels of serum endostatin and RIC.Some patients may develop resistant oedema and necrosis post GKRS for intracranial AVMs which may warrant medical and surgical intervention. Serum biomarkers like VEGF and Endostatin may vary in post GKRS period fpo can be used to identify at risk cases, however more studies are needed to decide on appropriate time of sampling and identify clinically relevant predictive factors.

Multistaged Stereotactic Radiosurgery for Complex Large Lobar Arteriovenous Malformations: A Case Series.

Although stereotactic radiosurgery (SRS) has well defined outcomes in the management of smaller-volume arteriovenous malformations (AVM), this report evaluates the outcomes when SRS is used for large-volume (≥10 cc) lobar AVMs. Between 1990 and 2022, a cohort of 1325 patients underwent Leksell Gamma Knife SRS for brain AVMs. Among these, 40 patients (25 women; median age: 37 years) with large lobar AVMs underwent volume-staged SRS followed by additional SRS procedures if needed (2-5 procedures). The patients presented with diverse AVM locations and Spetzler-Martin Grades. Before SRS, 16 patients underwent a total of 43 embolization procedures. Over a median follow-up of 73 months, 20 patients achieved AVM obliteration. The 3, 5, and 10-year obliteration rates were 9.3%, 15.3%, and 53.3%, respectively. During the latency interval between the first SRS procedure and the last follow-up, 11 patients had intracerebral hemorrhages (ICH) and 6 developed new neurological deficits unrelated to ICH. The postoperative hemorrhage risk after the first SRS was 13.8% at 3 years, 16.6% at 5 years, and 36.2% at 10 years. No hemorrhagic event was documented after confirmed obliteration. Compared with the modified Rankin Scale (mRS) scores before SRS, the mRS improved or remained stable in 28 patients. Nine patients died during the observation interval. Five were related to ICH. These outcomes underscore both the potential effectiveness and the limitations of multistage SRS procedures for complex high-risk large volume AVMs in critical brain lobar locations. Most patients retained either stable or improved long-term mRS scores. During the latency interval from the first SRS until obliteration, achieved after two or more procedures, the risk of hemorrhage and treatment-related complications persists.

Adenosine-assisted embolization of cerebral arteriovenous malformations: a systematic review and meta-analysis

BackgroundCerebral arteriovenous malformations (AVMs) are complex lesions that can cause hemorrhagic stroke and significant neurological disability. Adenosine induces cardiac standstill and hypotension, which are thought to be useful during cerebral...

Repeat Single-Session Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Systematic Review, Meta-Analysis, and International Stereotactic Radiosurgery Society Practice Guidelines.

Repeat stereotactic radiosurgery (SRS) for residual arteriovenous malformations (AVMs) can be considered as a salvage approach after failure of initial SRS. There are no published guidelines regarding patient selection, timing, or SRS parameters to guide clinical practice. This systematic review aimed to review outcomes and complications from the published literature to inform practice recommendations provided on behalf of the International Stereotactic Radiosurgery Society. We performed a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, Scopus, Web of Science, and Embase was conducted. Fourteen studies with 925 patients met the inclusion criteria. Patients were treated between 1985 and 2022. All studies were retrospective, except for one prospective cohort. The median patient age at repeat SRS ranged from 32 to 60 years. Four studies (630 patients) reported detailed information on Spetzler-Martin grade at the time of repeat SRS; 12.54% of patients had Spetzler-Martin grade I AVMs (79/630 patients), 46.51% had grade II (293/630), 34.92% had grade III (220/630), 5.08% had grade IV (32/630), and 0.95% had grade V (6/630). The median prescription doses varied between 15 and 25 Gy (mean, 13.06-22.8 Gy). The pooled overall obliteration rate at the last follow-up after repeat SRS was 59% (95% CI 51%-67%) with a median follow-up between 21 and 50 months. The pooled hemorrhage incidence at the last follow-up was 5% (95% CI 4%-7%), and the pooled overall radiation-induced change incidence was 12% (95% CI 7%-20%). For an incompletely obliterated AVM, repeat radiosurgery after 3 to 5 years of follow-up from the first SRS provides a reasonable benefit to the risk profile. After repeat SRS, obliteration is achieved in the majority of patients. The risk of hemorrhage or radiation-induced change appears low, and International Stereotactic Radiosurgery Society recommendations are presented.

Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale

Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale