{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T20:16:47Z","timestamp":1793132207978,"version":"4.5.0"},"reference-count":21,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,3,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV\u2013V) AVMs to enable comparison with published microsurgical series.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV\u2013V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8\u20139 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV\u2013V AVMs.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39\u20130.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93\u20130.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02\u20131.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82\u20131.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84\u20131.56, p = 0.38).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of \"inoperable\" AVMs according to Supp-SM grade (\u2265 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2022.5.jns22761","type":"journal-article","created":{"date-parts":[[2022,8,5]],"date-time":"2022-08-05T12:48:03Z","timestamp":1659703683000},"page":"804-809","source":"Crossref","is-referenced-by-count":13,"title":["Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system"],"prefix":"10.3171","volume":"138","author":[{"given":"Ryan M.","family":"Naylor","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher S.","family":"Graffeo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"},{"name":"Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cody L.","family":"Nesvick","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael J.","family":"Link","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul D.","family":"Brown","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott L.","family":"Stafford","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nadia N.","family":"Laack","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruce E.","family":"Pollock","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"4","key":"b1","series-title":"J Neurosurg","first-page":"476","article-title":"A proposed grading system for arteriovenous malformations","volume":"65","author":"Spetzler RF","year":"1986","unstructured":"Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476\u2013483.3760956"},{"issue":"4","key":"b2","series-title":"Neurosurgery","first-page":"702","article-title":"A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery","volume":"66","author":"Lawton MT","year":"2010","unstructured":"Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4):702\u2013713.20190666"},{"issue":"1","key":"b3","series-title":"J Neurosurg","first-page":"125","article-title":"Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system","volume":"136","author":"Catapano JS","year":"2021","unstructured":"Catapano JS, Frisoli FA, Nguyen CL,  Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system. J Neurosurg. 2021;136(1):125\u2013133.34171830"},{"issue":"6","key":"b4","series-title":"Neurosurgery","first-page":"1103","article-title":"Spetzler-Martin grade III arteriovenous malformations: a comparison of modified and supplemented Spetzler-Martin grading systems","volume":"88","author":"Frisoli FA","year":"2021","unstructured":"Frisoli FA, Catapano JS, Farhadi DS,  Spetzler-Martin grade III arteriovenous malformations: a comparison of modified and supplemented Spetzler-Martin grading systems. 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