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Robert F. Spetzler and Neil A. Martin

AVM's, educated surgical decision-making requires an objective method — a grading system — for predicting the risks of operation in individual cases of AVM's. An ideal grading system would define, for each specific AVM, the degree of difficulty involved in safely removing the malformation. Such a grading system should provide a reasonably accurate estimation of operative morbidity and mortality, and be simple yet comprehensive enough to be readily applied to all cerebral AVM's. Previously proposed grading schemes, which have been based only on AVM size or on the

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Peyton L. Nisson, Salman A. Fard, Christina M. Walter, Cameron M. Johnstone, Michael A. Mooney, Ali Tayebi Meybodi, Michael Lang, Helen Kim, Heidi Jahnke, Denise J. Roe, Travis M. Dumont, G. Michael Lemole Jr., Robert F. Spetzler, and Michael T. Lawton

. 35 Accurate risk stratification is important when considering surgical therapy, in terms of both patient decision-making and treatment strategy. A previous study by Rodríguez-Hernández et al. 35 found the most widely used grading system (the SM grading system) did not reliably convey the risk associated with treating these lesions. The objective of this study was to develop a powerful, yet simple and specific grading system to better guide vascular neurosurgeons’ decision-making and patient counseling for cerebellar AVMs, using the largest patient database

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Sam Safavi-Abbasi, Adrian J. Maurer, Jacob B. Archer, Ricardo A. Hanel, Michael E. Sughrue, Nicholas Theodore, and Mark C. Preul

D uring his lifetime and a career spanning 42 years at the Mayo Clinic (from 1922 to 1961) and at the Barrow Neurological Institute (from 1962 to 1964), James Watson Kernohan made numerous contributions to general pathology, neuropathology, neurology, and neurosurgery. However, there are two topics that represent especially enduring contributions that are significant to neurosurgery and the neurosurgical history of craniotomy. One continues to bear his name, 12 and the other is a grading system for gliomas geared toward a neurosurgical viewpoint that

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Robert F. Spetzler and Neil A. Martin

✓ An important factor in making a recommendation for treatment of a patient with arteriovenous malformation (AVM) is to estimate the risk of surgery for that patient. A simple, broadly applicable grading system that is designed to predict the risk of morbidity and mortality attending the operative treatment of specific AVM's is proposed. The lesion is graded on the basis of size, pattern of venous drainage, and neurological eloquence of adjacent brain. All AVM's fall into one of six grades. Grade I malformations are small, superficial, and located in non-eloquent cortex; Grade V lesions are large, deep, and situated in neurologically critical areas; and Grade VI lesions are essentially inoperable AVM's.

Retrospective application of this grading scheme to a series of surgically excised AVM's has demonstrated its correlation with the incidence of postoperative neurological complications. The application of a standardized grading scheme will enable a comparison of results between various clinical series and between different treatment techniques, and will assist in the process of management decision-making.

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Tai Seung Kim, Andrea L. Halliday, E. Tessa Hedley-Whyte, and Karen Convery

T he grading of astrocytomas has been the subject of many vigorous arguments. As a result, several grading systems exist; 17, 22–24, 29–31, 36 however, there is no universally accepted classification system. A numerical grading system for gliomas was developed by Kernohan, et al. 22, 23, 34 Kernohan's grading system, subdividing astrocytomas into grades 1 through 4, following a system first used for carcinomas by Broders, 3, 4 has been widely used. Ringertz 29 introduced a three-step grading system using the terms “astrocytoma,” “astrocytoma of

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Daniel W. Golden, Kathleen R. Lamborn, Michael W. McDermott, Sandeep Kunwar, William M. Wara, Jean L. Nakamura, and Penny K. Sneed

developed over the past 20 years, incorporating various combinations of known prognostic factors. These systems were developed in an attempt to improve prediction of those patients with brain metastases who have the best overall survival. The goal of this study was to determine whether the applicability of prognostic grading systems varies by primary tumor site in patients treated with radiosurgery for brain metastases. The following systems were evaluated: the RTOG RPA, 12 BSBM, 25 GPA, 36 and a newly proposed GGS ( Table 1 ). In support of this goal, we also

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Toru Serizawa, Yoshinori Higuchi, Osamu Nagano, Tatsuo Hirai, Junichi Ono, Naokatsu Saeki, and Akifumi Miyakawa

I n 2012, Yamamoto et al. 16 proposed a new subclassification for Class II patients in the Recursive Partitioning Analysis (RPA), which was originally reported by Gaspar et al. 3 in 1997. This new index was relatively simple to use in a clinical setting and proved to be applicable to patients with brain metastases who were treated with SRS. Several grading systems are available, however, such as the Score Index for Radiosurgery in Brain Metastases (SIR, Weltman and colleagues, 2000), 14 the Basic Score for Brain Metastases (BSBM, Lorenzoni and coworkers

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Neurosurgical Forum: Letters to the Editor To The Editor Ghaus M. Malik , M.D. James I. Ausman , M.D., Ph.D. Robert Mann , M.D. Henry Ford Hospital Detroit, Michigan 473 474 We have read with interest the paper by Drs. Spetzler and Martin (Spetzler RA, Martin NA: Proposed grading system for arteriovenous malformations. J Neurosurg 65: 476–483, October, 1986). There has long been a need for a grading system for cerebral arteriovenous malformations (AVM's) to grade the lesion

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Bruce E. Pollock and John C. Flickinger

two management strategies could be compared is extremely unlikely, physicians and their patients must choose the most appropriate treatment based on the available data. The Spetzler—Martin grading system 39 has become widely accepted as an accurate method to predict patient outcomes after resection of AVMs. Composed of three components (AVM size, location [eloquence of adjacent brain], and pattern of venous drainage), this system has been validated prospectively 11 and by personnel at numerous cerebrovascular centers of excellence. 13, 24, 25, 35 Although some

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Gabriel Zada, Parham Yashar, Aaron Robison, Jesse Winer, Alexander Khalessi, William J. Mack, and Steven L. Giannotta

objectively assess surgical tools for tumor resection may be improved by the application of a standardized grading system for tumor consistency. For these reasons, the authors aimed to establish and test the validity of an objective and practical grading system for meningioma consistency, which could more accurately account for the continuous, rather than binary, spectrum of meningioma texture, as well as accounting for regions of intratumoral heterogeneity with respect to consistency. We created a practical 5-point grading system to quantify the consistency of