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

Salem M. Tos; Mahmoud Osama; Georgios Mantziaris; Bardia Hajikarimloo; Nimer Adeeb; Sandeep Kandregula; Hamza Adel Salim; Basel Musmar; Christopher S. Ogilvy; Douglas Kondziolka; Adam A. Dmytriw; Kareem El Naamani; Ahmed Abdelsalam; Deepak Kumbhare; Sanjeev Gummadi; Cagdas Ataoglu; Muhammed Amir Essibayi; Ufuk Erginoglu; Abdullah Keles; Sandeep Muram; Daniel Sconzo; Howard Riina; Arwin Rezai; Johannes Pöppe; Rajeev D. Sen; Louis J. Kim; Omar Alwakaa; Christoph J. Griessenauer; Pascal Jabbour; Stavropoula I. Tjoumakaris; 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 Stapleton; 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

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, Mahmoud Osama, Georgios Mantziaris, Bardia Hajikarimloo, Nimer Adeeb, Sandeep Kandregula, Hamza Adel Salim, Basel Musmar, Christopher S. Ogilvy, Douglas Kondziolka, Adam A. Dmytriw, Kareem El Naamani, Ahmed Abdelsalam, Deepak Kumbhare, Sanjeev Gummadi, Cagdas Ataoglu, Muhammed Amir Essibayi, Ufuk Erginoglu, Abdullah Keles, Sandeep MuramDaniel Sconzo, Howard Riina, Arwin Rezai, Johannes Pöppe, Rajeev D. Sen, Louis J. Kim, Omar Alwakaa, Christoph J. Griessenauer, Pascal Jabbour, Stavropoula I. Tjoumakaris, 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 Stapleton, 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

Research output: Contribution to journal › Article › peer-review

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.

Original language	English
Article number	337
Journal	Neurosurgical Review
Volume	48
Issue number	1
DOIs	https://doi.org/10.1007/s10143-025-03465-6
State	Published - Dec 2025
Externally published	Yes

Keywords

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

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10.1007/s10143-025-03465-6

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Tos, S. M., Osama, M., Mantziaris, G., Hajikarimloo, B., Adeeb, N., Kandregula, S., Salim, H. A., Musmar, B., Ogilvy, C. S., Kondziolka, D., Dmytriw, A. A., Naamani, K. E., Abdelsalam, A., Kumbhare, D., Gummadi, S., Ataoglu, C., Essibayi, M. A., Erginoglu, U., Keles, A., ... Sheehan, J. (2025). Spetzler-martin grade IV cerebral arteriovenous malformations in adult patients: a propensity-score matched analysis of resection and stereotactic radiosurgery. Neurosurgical Review, 48(1), Article 337. https://doi.org/10.1007/s10143-025-03465-6

@article{9f546d8c82e94c249244959af7067fb3,

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

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",

author = "Tos, {Salem M.} and Mahmoud Osama and Georgios Mantziaris and Bardia Hajikarimloo and Nimer Adeeb and Sandeep Kandregula and Salim, {Hamza Adel} and Basel Musmar and Ogilvy, {Christopher S.} and Douglas Kondziolka and Dmytriw, {Adam A.} and Naamani, {Kareem El} and Ahmed Abdelsalam and Deepak Kumbhare and Sanjeev Gummadi and Cagdas Ataoglu and Essibayi, {Muhammed Amir} and Ufuk Erginoglu and Abdullah Keles and Sandeep Muram and Daniel Sconzo and Howard Riina and Arwin Rezai and Johannes P{\"o}ppe and Sen, {Rajeev D.} and Kim, {Louis J.} and Omar Alwakaa and Griessenauer, {Christoph J.} and Pascal Jabbour and Tjoumakaris, {Stavropoula I.} and Burkhardt, {Jan Karl} and Starke, {Robert M.} and Baskaya, {Mustafa K.} and Sekhar, {Laligam N.} and Levitt, {Michael R.} and Altschul, {David J.} and Neil Haranhalli and Malia McAvoy and Abdallah Abushehab and Assala Aslan and Christian Swaid and Adib Abla and Christopher Stapleton and Matthew Koch and Srinivasan, {Visish M.} and Chen, {Peng R.} and Spiros Blackburn and Omar Choudhri and Bryan Pukenas and Darren Orbach and Edward Smith and Markus M{\"o}hlenbruch and Ali Alaraj and Ali Aziz-Sultan and Patel, {Aman B.} and Amey Savardekar and Cuellar, {Hugo H.} and Kathleen Dlouhy and {El Ahmadieh}, Tarek and Michael Lawton and Adnan Siddiqui and Jacques Morcos and Bharat Guthikonda and Jason Sheehan",

note = "Publisher Copyright: {\textcopyright} The Author(s) 2025.",

year = "2025",

month = dec,

doi = "10.1007/s10143-025-03465-6",

language = "English",

volume = "48",

journal = "Neurosurgical Review",

issn = "0344-5607",

publisher = "Springer Science and Business Media Deutschland GmbH",

number = "1",

}

Tos, SM, Osama, M, Mantziaris, G, Hajikarimloo, B, Adeeb, N, Kandregula, S, Salim, HA, Musmar, B, Ogilvy, CS, Kondziolka, D, Dmytriw, AA, Naamani, KE, Abdelsalam, A, Kumbhare, D, Gummadi, S, Ataoglu, C, Essibayi, MA, Erginoglu, U, Keles, A, Muram, S, Sconzo, D, Riina, H, Rezai, A, Pöppe, J, Sen, RD, Kim, LJ, Alwakaa, O, Griessenauer, CJ, Jabbour, P, Tjoumakaris, SI, Burkhardt, JK, Starke, RM, Baskaya, MK, Sekhar, LN, Levitt, MR, Altschul, DJ, Haranhalli, N, McAvoy, M, Abushehab, A, Aslan, A, Swaid, C, Abla, A, Stapleton, C, Koch, M, Srinivasan, VM, Chen, PR, Blackburn, S, Choudhri, O, Pukenas, B, Orbach, D, Smith, E, Möhlenbruch, M, Alaraj, A, Aziz-Sultan, A, Patel, AB, Savardekar, A, Cuellar, HH, Dlouhy, K, El Ahmadieh, T, Lawton, M, Siddiqui, A, Morcos, J, Guthikonda, B & Sheehan, J 2025, 'Spetzler-martin grade IV cerebral arteriovenous malformations in adult patients: a propensity-score matched analysis of resection and stereotactic radiosurgery', Neurosurgical Review, vol. 48, no. 1, 337. https://doi.org/10.1007/s10143-025-03465-6

TY - JOUR

T1 - Spetzler-martin grade IV cerebral arteriovenous malformations in adult patients

T2 - a propensity-score matched analysis of resection and stereotactic radiosurgery

AU - Tos, Salem M.

AU - Osama, Mahmoud

AU - Mantziaris, Georgios

AU - Hajikarimloo, Bardia

AU - Adeeb, Nimer

AU - Kandregula, Sandeep

AU - Salim, Hamza Adel

AU - Musmar, Basel

AU - Ogilvy, Christopher S.

AU - Kondziolka, Douglas

AU - Dmytriw, Adam A.

AU - Naamani, Kareem El

AU - Abdelsalam, Ahmed

AU - Kumbhare, Deepak

AU - Gummadi, Sanjeev

AU - Ataoglu, Cagdas

AU - Essibayi, Muhammed Amir

AU - Erginoglu, Ufuk

AU - Keles, Abdullah

AU - Muram, Sandeep

AU - Sconzo, Daniel

AU - Riina, Howard

AU - Rezai, Arwin

AU - Pöppe, Johannes

AU - Sen, Rajeev D.

AU - Kim, Louis J.

AU - Alwakaa, Omar

AU - Griessenauer, Christoph J.

AU - Jabbour, Pascal

AU - Tjoumakaris, Stavropoula I.

AU - Burkhardt, Jan Karl

AU - Starke, Robert M.

AU - Baskaya, Mustafa K.

AU - Sekhar, Laligam N.

AU - Levitt, Michael R.

AU - Altschul, David J.

AU - Haranhalli, Neil

AU - McAvoy, Malia

AU - Abushehab, Abdallah

AU - Aslan, Assala

AU - Swaid, Christian

AU - Abla, Adib

AU - Stapleton, Christopher

AU - Koch, Matthew

AU - Srinivasan, Visish M.

AU - Chen, Peng R.

AU - Blackburn, Spiros

AU - Choudhri, Omar

AU - Pukenas, Bryan

AU - Orbach, Darren

AU - Smith, Edward

AU - Möhlenbruch, Markus

AU - Alaraj, Ali

AU - Aziz-Sultan, Ali

AU - Patel, Aman B.

AU - Savardekar, Amey

AU - Cuellar, Hugo H.

AU - Dlouhy, Kathleen

AU - El Ahmadieh, Tarek

AU - Lawton, Michael

AU - Siddiqui, Adnan

AU - Morcos, Jacques

AU - Guthikonda, Bharat

AU - Sheehan, Jason

PY - 2025/12

Y1 - 2025/12

N2 - 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.

AB - 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.

KW - AVM obliteration

KW - Cerebral arteriovenous malformations

KW - Complication rates and functional outcomes

KW - Resection

KW - Spetzler-martin grade IV

KW - Stereotactic radiosurgery

UR - http://www.scopus.com/inward/record.url?scp=105001558277&partnerID=8YFLogxK

U2 - 10.1007/s10143-025-03465-6

DO - 10.1007/s10143-025-03465-6

M3 - Article

AN - SCOPUS:105001558277

SN - 0344-5607

VL - 48

JO - Neurosurgical Review

JF - Neurosurgical Review

IS - 1

M1 - 337

ER -

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

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Keywords

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