To depict the surgical nuances of brain arteriovenous malformation (AVM) resection and propose an additional factor to refine the Supplementary Spetzler-Martin (sSM) grading system.

Surgical resection remains the definitive treatment for AVMs, but intraoperative bleeding, incomplete resection, and postoperative complications are persistent challenges. The sSM grading system attempts to include patient factors in defining surgical risk, but the patient’s Glasgow Coma Scale (GCS) may be a key factor that has not been considered.

In this single-center study, 26 patients underwent surgical resection of brain AVMs by the senior author between 2016 and 2023. The technical nuances, as demonstrated by the surgeon (with video demonstrations of the surgical procedure available during the presentation), were evaluated along with clinical and imaging features, blood loss, ICU stay, and postoperative functional outcomes. We assessed the relationship between the level of consciousness, sSM grading, surgical risk, and long-term KPS score.

Duration of ICU stay and intraoperative blood loss showed significant negative correlations with the primary GCS of the patients (p<0.0001 and p=0.001, respectively). Integrating GCS into the sSM grading system significantly improved the correlation with postoperative KPS scores (p=0.0002).

Several surgical considerations, such as the extent of craniotomy, optimal location for disconnecting feeders, when to sacrifice deep and superficial veins, and how to control bleeding from deep feeders, must be accounted to optimize surgical outcomes in brain AVM resection. Adding the patient’s level of consciousness to the sSM grading system could provide a more reliable prediction of surgical risk and outcomes.