Paul P. Huang et al. “Long-term Outcomes After Staged-VolumeStereotactic Radiosurgery for Large Arteriovenous Malformations” Neurosurgery 71:632–644, September 2012 David Bervini JC, ASAM 18.10.2012
23 ml = 23 cm3• 2.8 cm side cube • 3.5 cm diameter sphere LARGE?
SM (3)-4-5 -> ELOQUENT AREAS LARGE: “radiosurgical definition”44% embolization before radiosurgery When? Selection bias Good recovery!
• Only 12 underwent FU DSA Attrition bias• FU < 10y Long-term?
Statistical Analysis KM curvesNo information about comparison between curves (Cox-Mantel log-rank test? Gehan- Breslow-Wilcoxon test? Peto modification?) No Cox regression analysis Statistical bias
TOT Occlusion rate 61% 29%
31%, in eloquent regions!
P >> .05
Number at risk after 5yrs?
Seizure Control Neurological deficits 10 Pts before ttt 5 before ttt 6 stable 2 worsening3 transient increase (not related to heamorrhage) 1 improvedNo positive impact of No positive impact of treatment treatment
Take away message + -Strict radiosurgery protocol Poor design respected for 13yrs Many bias Good economy of words Very poor statistical analysisGood organization of paper and powerGood relevance and accuracy of bibliography Distracting graphs (radiosurgery) Debatable resultsGood quality of illustrations
This paper does not help me to understand the indications and advantages of fractioned radiosurgery for patients presenting with “large”, “symptomatic” AVMs.