Journal Reading

Validation of the Supplemented Spetzler-Martin

Grading System for Brain Arteriovenous
Malformations in a Multicenter Cohort of 1009
Surgical Patients

Neurosurgery 7 6:2533, 2015

Michael T. Lawton, MD,et al

Fajar R. Qimindra,dr.
Supervisor:

Azra Al Fauzi, dr., Sp.BS

Nur Setiawan Suroto, dr. Sp.BS
Faculty of Medicine Airlangga University Dr Soetomo General Hospital
Surabaya - 2015

Background

The supplementary grading system for

brain arteriovenous malformations (AVMs)
was introduced in 2010 as a tool for
improving preoperative risk prediction and
selecting surgical patients.

Through analysis of additional factors

outside the Spetzler-Martin (SM) grading
system that influence patient outcome
after AVM resection, an analogous grading
system was constructed that would
supplement, rather than replace, the
entrenched SM system
2

ABCs for AVMs:

The supplemented SM (SM-Supp) score, 6

identified patients with :
1. acceptably low surgical morbidity
2. providing a bedside numerical boundary
for safe surgery

Objective
To demonstrate in this multicenter
validation study that supplemented
Spetzler-Martin (SM-Supp) grades have
greater predictive accuracy than
Spetzler-Martin (SM) grades alone

Methods

Study Variables

Results
1. The SM-Supp system performed better
than SM
system alone:
area under the receiver-operating
characteristics curve (AUROC) = 0.75(95%
CI, 0.71-0.78) for SM-Supp
(AUROC) = 0.69 (95% CI, 0.65-0.73)
for SM

Results

Unruptured AVM size

<3 cm : 78 3-6 cm : 6

> 6 cm :
4

Unruptured AVM SM grade

I : 9%

II :
45.8%

III :
34.8%

IV : 9%

V:
1.4%

Results

2. Stratified analysis fitting models within 3

different
follow-up groupings (<6 months, 6
months-2 years, and >2 years)
demonstrated that
the SM-Supp system performed better
than SM system for both medium (AUROC
= 0.71
vs 0.62; P = .003) and long (AUROC =
0.69 vs 0.58; P = .001) follow-up
3. Patients with SMSupp grades 6 had
acceptably low surgical risks (0%-24%),
with a significant increase in
risk for grades > 6 (39%-63%).

11

12

Limitations
This study is limited by
selection and inclusion
biases.

Conclusion
This study validates the predictive
accuracy of the SM-Supp system in a
multicenter cohort.
An SM-Supp grade of 6 is a cutoff or
boundary for AVM operability.
Supplemented grading is currently the
best method of estimating neurological
outcomes after AVM surgery, and we
recommend it as a starting point in the
evaluation of AVM operability.

Thank You !