title: Microsurgical resection of Spetzler-Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management--results of a single group series.
abstract: BACKGROUND
  The therapeutic benefits of microsurgery for unruptured brain AVM remain unclear.
  
  
  METHODS
  A series of 97 microsurgically resected unruptured brain AVM was analyzed in terms of postoperative morbidity and lifetime loss of quality-adjusted life-years (QALY). For comparison, the natural risk of becoming disabled was modeled on the basis of published data.
  
  
  RESULTS
  Discharge morbidity was recorded in 11 of the 69 of Spetzler-Martin (SM) grade 1 and 2 AVMs (16 %), eight of 22 (36 %) grade 3, and four of six grade 4 (67 %), permanent morbidity >mRS 1 in 3 (4.3 %) grade 1 and 2, four (18 %) grade 3, and three (50 %) grade 4. Treatment inflicted loss of QALY amounted to 0.5 years for SM grade 1-2, 2.5 years grade 3, 7.3 years for grade 4. For the SM grades 1 and 2, the treatment-related loss of 0.5 QALY was met by the natural course after 2.7-4.3 years. For the Spetzler-Martin grades 3 and 4, the treatment-induced loss QALY was not met by the natural risk within a foreseeable time. Permanent morbidity and treatment inflicted loss of QALY of patients younger than 39 years was lower than that of older patients (7 vs. 15 % and 1.0 vs. 2.1 QALY).
  
  
  CONCLUSIONS
  Microsurgically managed SM grades 1 and 2 fared better than the modeled natural course but grades 3 and 4 AVM did not benefit from surgery. Younger patients appear to fare more favorably than older patients.
authors.affiliation: Department of Neurosurgery, Heinrich-Heine-Universität, Moorenstr. 5, Geb. 10.54, 40225, Düsseldorf, Germany, steiger@uni-duesseldorf.de.
authors.forename: Hans-Jakob
authors.initials: HJ
authors.lastname: Steiger
authors.forename: Igor
authors.initials: I
authors.lastname: Fischer
authors.forename: Benjamin
authors.initials: B
authors.lastname: Rohn
authors.forename: Bernd
authors.initials: B
authors.lastname: Turowski
authors.forename: Nima
authors.initials: N
authors.lastname: Etminan
authors.forename: Daniel
authors.initials: D
authors.lastname: Hänggi
mesh_terms: D000328:Adult; D004621:Embolization, Therapeutic / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery* / Q000628:therapy; D008297:Male; D008866:Microsurgery / Q000009:adverse effects* / Q000379:methods; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D016634:Radiosurgery / Q000009:adverse effects* / Q000379:methods; D016896:Treatment Outcome