jc 18.10.2012
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Paul P. Huang et al.
“Long-term Outcomes After Staged-Volume Stereotactic Radiosurgery for Large Arteriovenous Malformations”
Neurosurgery 71:632–644, September 2012
David BerviniJC, ASAM
18.10.2012
PATIENTS AND METHODS
Prospective
Cases series, not randomized
Strong radiosurgery protocol
M 35y (3)-4-5M 23ml
23 ml = 23 cm3
• 2.8 cm side cube • 3.5 cm diameter sphere
LARGE?
SM (3)-4-5 -> ELOQUENT AREAS
When?
Good recovery!
Selection bias
LARGE: “radiosurgical definition”
44% embolization before radiosurgery
• Only 12 underwent FU DSA
• FU < 10y
Attrition bias
Long-term?
Statistical Analysis
KM curves
No information about comparison between curves (Cox-Mantel log-rank test? Gehan-
Breslow-Wilcoxon test? Peto modification?)
No Cox regression analysis
Statistical bias
RESULTS
TOT Occlusion rate 61%
29%
Information bias
31%, in eloquent regions!
P >> .05
Number at risk after 5yrs?
Seizure Control
10 Pts before ttt
6 stable3 transient increase
1 improved
No positive impact of treatment
Neurological deficits
5 before ttt
2 worsening (not related to heamorrhage)
No positive impact of treatment
Take away message
+Strict radiosurgery protocol
respected for 13yrs
Good economy of words
Good organization of paper
Good relevance and accuracy of bibliography (radiosurgery)
Good quality of illustrations
-Poor design
Many bias
Very poor statistical analysis and power
Distracting graphs
Debatable results
This paper does not help me to understand the indications and advantages of fractioned radiosurgery for patients presenting with
“large”, “symptomatic” AVMs.
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