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. 2025 Mar 31;48(1):337.
doi: 10.1007/s10143-025-03465-6.

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

Salem M Tos  1 , Mahmoud Osama  1 , Georgios Mantziaris  1 , Bardia Hajikarimloo  1 , Nimer Adeeb  2   3 , Sandeep Kandregula  4 , Hamza Adel Salim  5 , Basel Musmar  6 , Christopher S Ogilvy  7 , Douglas Kondziolka  8 , Adam A Dmytriw  9 , Kareem El Naamani  6 , Ahmed Abdelsalam  10 , Deepak Kumbhare  2 , Sanjeev Gummadi  2 , Cagdas Ataoglu  11 , Muhammed Amir Essibayi  12 , Ufuk Erginoglu  11 , Abdullah Keles  11 , Sandeep Muram  7 , Daniel Sconzo  7 , Howard Riina  8 , Arwin Rezai  13 , Johannes Pöppe  13 , Rajeev D Sen  14 , Louis J Kim  14 , Omar Alwakaa  7 , Christoph J Griessenauer  13 , Pascal Jabbour  6 , Stavropoula I Tjoumakaris  6 , Jan-Karl Burkhardt  4 , Robert M Starke  10 , Mustafa K Baskaya  11 , Laligam N Sekhar  14 , Michael R Levitt  14 , David J Altschul  12 , Neil Haranhalli  12 , Malia McAvoy  15 , Abdallah Abushehab  16 , Assala Aslan  5 , Christian Swaid  2 , Adib Abla  10 , Christopher Stapleton  9 , Matthew Koch  17 , Visish M Srinivasan  4 , Peng R Chen  3 , Spiros Blackburn  3 , Omar Choudhri  4 , Bryan Pukenas  4 , Darren Orbach  9 , Edward Smith  18 , Markus Möhlenbruch  19 , Ali Alaraj  20 , Ali Aziz-Sultan  21 , Aman B Patel  9 , Amey Savardekar  2 , Hugo H Cuellar  2 , Kathleen Dlouhy  22 , Tarek El Ahmadieh  23 , Michael Lawton  24 , Adnan Siddiqui  25 , Jacques Morcos  3 , Bharat Guthikonda  2 , Jason Sheehan  26   27
Affiliations

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

Salem M Tos et al. Neurosurg Rev. .

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.

Keywords: AVM obliteration; Cerebral arteriovenous malformations; Complication rates and functional outcomes; Resection; Spetzler-martin grade IV; Stereotactic radiosurgery.

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Conflict of interest statement

Declarations. Ethical approval: This retrospective multicenter clinical cohort study was conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of University of Virginia Hospital. Due to the retrospective nature of the study, the requirement for informed consent was waived by the IRB. All patient data were anonymized and de-identified prior to analysis to ensure patient confidentiality. Human ethics and consent to participate: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
High-grade brain arteriovenous malformation (AVM) with treatment options: embolization, resection, and radiosurgery
Fig. 2
Fig. 2
Comparison of obliteration status between resection and stereotactic radiosurgery (SRS) cohorts, presented for both original and matched data. Resection shows a higher complete obliteration rate (p < 0.01)
Fig. 3
Fig. 3
Comparison of complication between resection and stereotactic radiosurgery (SRS) cohorts, presented for both original and matched data
Fig. 4
Fig. 4
Comparison of last recorded modified Rankin Scale (mRS) scores to pre-treatment mRS between resection and stereotactic radiosurgery (SRS) cohorts, shown for original and matched data
Fig. 5
Fig. 5
Baseline characteristics of patients undergoing resection versus stereotactic radiosurgery (SRS) for Grade IV arteriovenous malformations (AVMs)
See this image and copyright information in PMC

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