Spetzler-martin grade IV cerebral arteriovenous malformations in adult patients: a propensity-score matched analysis of resection and stereotactic radiosurgery

• DOI: 10.1007/s10143-025-03465-6
• Publication Date: 2025-04-01T09:14:55Z
• Authors: Salem M. Tos; Mahmoud Osama; Georgios Mantziaris; Bardia Hajikarimloo; Nimer Adeeb; Sandeep Kandregula; Hamza Adel Salim; Basel Musmar; Christopher S. Og...; Douglas Kondziolka; Adam A. Dmytriw; Kareem El Naamani; Ahmed Abdelsalam; Deepak Kumbhare; Sanjeev Gummadi; Cagdas Ataoglu; Muhammed Amir Ess...; Ufuk Erginoglu; Abdullah Keles; Sandeep Muram; Daniel Sconzo; Howard Riina; Arwin Rezai; Johannes Pöppe; Rajeev D. Sen; Louis J. Kim; Omar Alwakaa; Christoph J. Grie...; Pascal Jabbour; Stavropoula I. Tj...; Jan-Karl Burkhardt; Robert M. Starke; Mustafa K. Baskaya; Laligam N. Sekhar; Michael R. Levitt; David J. Altschul; Neil Haranhalli; Malia McAvoy; Abdallah Abushehab; Assala Aslan; Christian Swaid; Adib Abla; Christopher Stapl...; Matthew Koch; Visish M. Srinivasan; Peng R. Chen; Spiros Blackburn; Omar Choudhri; Bryan Pukenas; Darren Orbach; Edward Smith; Markus Möhlenbruch; Ali Alaraj; Ali Aziz-Sultan; Aman B. Patel; Amey Savardekar; Hugo H. Cuellar; Kathleen Dlouhy; Tarek El Ahmadieh; Michael Lawton; Adnan Siddiqui; Jacques Morcos; Bharat Guthikonda; Jason Sheehan

Abstract 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.

Graphical Abstract