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Microvascular Decompression: Salient Surgical Principles and Technical Nuances
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Is Supplemented Spetzler-Martin grading Superior? A comparative study in AVM microsurgery risk stratification.

Cyrus Raki1, Chris Xenos2, Leon T Lai2

  • 1School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia.

Journal of Clinical Neuroscience : Official Journal of the Neurosurgical Society of Australasia
|May 11, 2025
PubMed
Summary

The Supplemented Spetzler-Martin (Supp-SM) grading system shows stronger correlation with neurological outcomes after brain arteriovenous malformation (AVM) surgery than the standard SM system. A Supp-SM score of 6 or higher indicates significantly higher surgical risk and morbidity.

Keywords:
ComparisonMicrosurgerySpetzler-Martin GradingSupplemented Spetzler-Martinbrain AVMs

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Area of Science:

  • Neurosurgery
  • Cerebrovascular Surgery
  • Neurological Outcomes
  • Arteriovenous Malformations

Background:

  • The Spetzler-Martin (SM) grading system is the standard for classifying brain arteriovenous malformations (AVMs).
  • The Supplemented Spetzler-Martin (Supp-SM) system was developed to enhance surgical risk stratification by including patient age, rupture status, and nidus diffuseness.
  • Limited data exist comparing the predictive validity of the SM and Supp-SM grading systems for surgical outcomes.

Purpose of the Study:

  • To investigate the predictive relevance of both the SM and Supp-SM grading systems for postoperative neurological morbidity after AVM microsurgery.
  • To compare the accuracy of the SM and Supp-SM systems in stratifying surgical risk and predicting patient outcomes.

Main Methods:

  • Retrospective review of 96 patients who underwent AVM microsurgical resection between 2015 and 2024.
  • Postoperative morbidity was defined as an increased modified Rankin Scale (mRS) score at 90 days.
  • Predictive accuracy was assessed using Receiver Operating Characteristic (ROC) curves, correlation with postoperative mRS scores, and analysis of the Supp-SM risk threshold.

Main Results:

  • Postoperative morbidity occurred in 9.4% of patients.
  • ROC analysis showed no significant difference in predictive accuracy between SM (AUROC 0.717) and Supp-SM (AUROC 0.667) grading systems (p=0.3899).
  • Supp-SM scores demonstrated a stronger correlation with postoperative mRS changes (Spearman's ρ=0.269, p=0.008) compared to SM grades (Spearman's ρ=0.144, p=0.161).
  • Patients with Supp-SM grades < 6 had a 3.2% morbidity risk, while those with scores ≥ 6 had a 20.6% risk (p=0.009).
  • A Supp-SM threshold of 6 showed the highest discriminative accuracy for identifying high-risk surgical candidates.

Conclusions:

  • While both SM and Supp-SM grading systems showed no significant difference in overall predictive accuracy, the Supp-SM system offers improved correlation with neurological morbidity.
  • A Supp-SM score of 6 or greater is associated with substantially higher postoperative neurological morbidity.
  • The findings support the adjunctive use of the Supp-SM grading system for more refined surgical risk assessment in patients with brain arteriovenous malformations.