A 3-tier classification of cerebral arteriovenous malformations

Spetzler, Robert F.; Ponce, Francisco A.

doi:10.3171/2010.8.jns10663

Cited by 271 publications

(194 citation statements)

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“…The recent work of Bervini and colleagues, Nerva and colleagues, as well as the report in the current issue provide sufficient substance to recommend microsurgery to patients with unruptured AVM Spetzler-Martin grade 1 and 2 (corresponding to Spetzler-Ponce class A) [3,11,14,16]. In contrast, treatment of unruptured Spetzler-Martin grade 3 and 4 AVMs needs to be seen critically.…”

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confidence: 92%

“…The surgical case fatality rate for brain AVM was in the range of 15 % prior to introduction of endovascular therapy and has decreased to almost zero since [12,19]. Complex Spetzler-Martin grade 3 and 4 AVMs (corresponding to the recently introduced Spetzler-Ponce classes B and C) have become manageable with the introduction of endovascular therapy as a preparatory adjunct for subsequent microsurgical removal [14].…”

mentioning

confidence: 99%

“…Here, any treatment appears to be as risky as or riskier than the natural history. It is important to consider microsurgical treatment of unruptured AVMs Spetzler-Martin grade 1 and 2 as a stand-alone therapy, as it has been recently proposed by Spetzler and his group and by other eminent neurovascular surgeons [10,14]. Unruptured brain AVM present a substantial burden for patients with a 2.3 % annual risk of rupture resulting with 50 % chance in death or permanent disability.…”

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confidence: 99%

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Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Steiger

Schaller

2015

Acta Neurochir

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We appreciate the thoughtful comments of T.R. Meling and the support of a constructive strategy regarding unruptured brain AVM. The results of the ARUBA trial have been widely commented on and the weaknesses of the study have been pointed out, i.e., the lack of differentiation between Spetzler-Martin grades and treatment modalities, and the fact that the effect of microsurgical removal was not assessed by the study design [4,8,9]. The report of the Scottish Audit of Intracranial Vascular Malformations drew less attention, but provided essentially the same result that intervention led to a worse outcome compared to the natural history [1]. The results of ARUBA and the Scottish Audit of Intracranial Vascular Malformations showed an almost identical pattern of strokes following intervention, with initially a higher rate of events than in untreated patients and secondary regression to the rate of the natural history. Therefore, we have to accept that the way we have been treating unruptured AVM was not right and needs correction.As pointed out by Meling, the treatment-associated morbidity rates as given in the ARUBA trial, and also the Scottish Audit, are very different from the rates given in microsurgical series. The high morbidity rates of ARUBA and the Scottish Audit are the footprint of destabilized and incompletely eliminated AVM, i.e., the pattern of endovascular embolization [19]. Without any doubt, radiosurgery contributed to the continuing stroke rate in the interventional cohorts but was unlikely a major factor for the increased rate following intervention.Despite the obvious pattern of the delayed hemorrhages in the ARUBA and the Scottish Audit cohorts, questions remain. All non-randomized series provided rates of stroke after microsurgery, radiosurgery, and embolization far below the 9-10 % per year rate of ARUBA and the Scottish Audit. Probability of hemorrhage after successful microsurgery appears, however, to be approximately one-tenth the rate after endovascular embolization, according to the meta-analysis of van Beijnum [19]. Although the numbers of hemorrhages given in nonrandomized series remain far below the incidence rates in ARUBA and the Scottish cohort, it appears likely that endovascular therapy was the primary factor for the exorbitant event rate following intervention. Analyzing all published series, van Beijnum and coworkers found reported annual hemorrhage rates of 0.18 % after microsurgery 1.7 % after stereotactic radiosurgery and 1.7 % after embolization. The obvious destabilizing effect resulting from treatment as seen in the ARUBA and Scottish Audit cohorts is hardly explainable by radiosurgery.Endovascular intranidal embolization emerged in the 1980s as a minimally invasive alternative to surgical elimination. It was soon realized, however, that complete elimination could not be routinely achieved. The introduction of Onyx, offering more controllable intranidal dispersion, did not change the picture fundamentally, achieving complete elimination in maximally 50 % [5,13,16]. Emboliza...

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confidence: 99%

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confidence: 99%

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Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Steiger

Schaller

2015

Acta Neurochir

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“…8). An AVM is classified according to its size, location and type of venous drainage [46]. The individual risk of hemorrhage depends on a number of factors, including location, drainage via the deep brain veins and the presence of an aneurysm in the feeder vessels [39].…”

Section: Arteriovenous Malformations (Avm)mentioning

confidence: 99%

Management of Intracranial Incidental Findings on Brain MRI

Langner

Buelow

Fleck

et al. 2016

Fortschr Röntgenstr

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The wider use of MRI for imaging of the head in both research and clinical practice has led to an increasing number of intracranial incidental findings. Most of these findings have no immediate medical consequences. Nevertheless, knowledge of common intracranial incidental findings and their clinical relevance is necessary to adequately discuss the findings with the patient. Based on the author?s experiences from a large population-based study, the most common incidental MR findings in the brain will be presented, discussing their clinical relevance and giving recommendations for management according to the current literature and guidelines. Key points: ??Intracranial incidental findings are common. ??The majority of these findings have no immediate medical consequences. ??Knowledge of common incidental findings is necessary for appropriate management. Citation Format: ??Langner S, Buelow R, Fleck S et?al. Management of Intracranial Incidental Findings on Brain MRI. Fortschr R?ntgenstr 2016; 188: 1123???1133

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“…34) The grading system by Spetzler and Martin has been widely used to assess the surgical difficulty of cerebral AVM. 47) Spetzler-Martin grade 3 or higher lesions are considered to have higher risk for surgery, 23,47,48) and also have higher risk of morbidity associated with SRS because of the usually large size or location in cortical eloquent areas. 12) Since SRS using gamma knife surgery (GKS) is designed to deliver high dose irradiation to a small target, AVM with a large nidus volume is not an ideal target.…”

Section: Introductionmentioning

confidence: 99%

Role of Stereotactic Radiosurgery in the Treatment of High-Grade Cerebral Arteriovenous Malformation

Hanakita

Koga

Shin

et al. 2012

Neurol. Med. Chir.(Tokyo)

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Arteriovenous malformation (AVM) with a small nidus located in the cortical eloquent areas is difficult to surgically resect without neurological complication, but is a suitable target for stereotactic radiosurgery (SRS). However, lesions with large nidus volume or with deeply located nidus are difficult to safely treat, even by SRS. To explore the optimal treatment strategies for such high-grade cerebral AVM, we reviewed treatment outcomes of SRS using gamma knife surgery (GKS) for patients with high-grade AVM at our institute and in published reports. Although lesions in the thalamus and the brainstem carried higher risk of morbidity after SRS, accumulation of technical knowledge and experience about SRS and technological advances in dose planning have enabled safer treatment of AVM in these locations. Large AVM presents another challenge to SRS treatment. Multimodal treatment, including surgery and endovascular treatment, should be considered. In this setting, staged SRS using GKS or CyberKnife may achieve safer treatment of large cerebral AVM. Further progress in SRS is anticipated to enhance the treatment efficacy for high-grade cerebral AVM while reducing treatment morbidity.

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A 3-tier classification of cerebral arteriovenous malformations

Cited by 271 publications

References 38 publications

Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Management of Intracranial Incidental Findings on Brain MRI

Role of Stereotactic Radiosurgery in the Treatment of High-Grade Cerebral Arteriovenous Malformation

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