Microsurgical treatment of arteriovenous malformations: analysis and comparison with stereotactic radiosurgery

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  • 1 Departments of Surgery (Section of Neurosurgery), Anesthesiology, and Community and Family Medicine (Biostatistics), Dartmouth—Hitchcock Medical Center, Lebanon, New Hampshire
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Object. To compare microsurgical and stereotactic radiosurgical treatment of arteriovenous malformations (AVMs), the authors analyzed a prospective series of 72 consecutive patients who were treated microsurgically for cerebral AVMs by one neurosurgeon. The authors then compared the results of microsurgical treatment with published results of stereotactic radiosurgical treatment of small AVMs.

Methods. Patients were categorized by age, gender, presentation, and preoperative neurological status. The AVMs were categorized by size, location, presence of deep venous drainage, and Spetzler—Martin grade. Outcome was assessed for angiographic obliteration, hemorrhage following treatment, presence of a new, persistent postoperative neurological deficit, and Glasgow Outcome Scale (GOS) score. Ordinal logistic regression was used to model the GOS score and to predict new postoperative deficits. Generalized estimating equations were used to compare published results of microsurgical and stereotactic radiosurgical treatment of AVMs. Kaplan—Meier event-free survival plots were generated to compare the two modalities with respect to hemorrhage following treatment.

Overall, six patients (8.3%) exhibited a new persistent neurological deficit postoperatively. Sixty-five patients (90.3%) had a GOS score of 5. Three patients were moderately disabled and four patients were severely disabled. No patient was observed to be in a vegetative state and there were no treatment-related deaths. Seventy-one patients (98.6%) underwent intra- or postoperative angiography. Total excision of the AVM was angiographically confirmed in 70 patients (98.6% of those who underwent angiography). To date no patient has suffered from hemorrhage since the microsurgical treatment. When analysis was confined to patients whose AVMs were smaller than 3 cm in maximum diameter, the authors found a 100% angiographic obliteration rate, no new postoperative neurological deficit, and a good recovery in all patients. An analysis of all patients with Spetzler—Martin Grades I to III resulted in a 100% rate of angiographic obliteration, one patient with a new postoperative neurological deficit, and good recovery in 93% of the patients.

Size of the AVM, preoperative neurological status, and patient age are associated with GOS score (for all, p <0.02). The Spetzler—Martin grading system as well as each component of this system are associated with the development of a new postoperative neurological deficit (for all, p < 0.01). For the entire series there were fewer postoperative hemorrhages and deaths than those mentioned in published series of small AVMs treated with stereotactic radiosurgery. When these patients and published series of patients with microsurgically treated AVMs classified as Grade I to III were compared with similar patients treated radiosurgically there were significantly fewer postoperative hemorrhages (odds ratio = 0.210, p = 0.001), fewer deaths (odds ratio = 0.659, p = 0.019), fewer new posttreatment neurological deficits (odds ratio = 0.464, p = 0.013), and a higher incidence of obliteration (odds ratio = 28.2, p = 0.001) for the microsurgical group. Lifetable analysis confirms the statistically significant difference in hemorrhage-free survival time between the two groups (p = 0.002).

Conclusions. Based on this analysis, microsurgical treatment of Grades I to III AVMs is superior to stereotactic radiosurgery.

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Contributor Notes

Address for Dr. Pikus: University of Miami School of Medicine, Miami, Florida.Address reprint requests to: Robert E. Harbaugh, M.D., Department of Surgery (Neurosurgery), Dartmouth—Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756.
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