title: Embolization of cerebral arteriovenous malformations with silk suture particles prior to stereotactic radiosurgery.
abstract: We aimed to determine the long term durability of silk suture and polyvinyl alcohol (PVA) particle embolization (SPE) of arteriovenous malformations (AVM), and to evaluate the outcomes following multimodality management of AVM with combined SPE and stereotactic radiosurgery (SRS). A general supposition among neurointerventionalists is that embolization of cerebral AVM with silk sutures and PVA particles does not yield a durable occlusion. We performed a retrospective review of all AVM patients treated at our institution with combined SPE and SRS. After extracting the baseline, embolization and SRS data for each patient, the durability of SPE was determined by evaluating the postembolization recanalization between the last procedural angiogram and the most recent neuroimaging. Four AVM patients who underwent a total of nine SPE procedures through 21 arterial pedicles were included for the analyses. The nidus volumes were 5.8-75 cm(3) and the Spetzler-Martin grades were II and V in one patient and III in two patients. The median degree of devascularization per procedure was <25%. There were no procedural complications, with all patients maintaining functional independence after embolization (modified Rankin scale score 0-2). After a median follow-up duration of 27 months (range: 23-36), there were no patients with recanalization. SRS (marginal dose 13-18 Gy) resulted in 40 to >95% volume reduction. Following SRS, one patient remained asymptomatic, two patients improved, and one patient deteriorated due to a latency period AVM hemorrhage. In conclusion, SPE can safely provide durable AVM devascularization, therefore, appropriately selected nidi can be effectively treated with combined SPE and SRS.
authors.affiliation: Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.affiliation: Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
authors.affiliation: Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.affiliation: Department of Radiology and Medical Imaging, University of Virginia, Post Office Box 800170, Charlottesville, VA 22908, USA.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Durst
authors.affiliation: Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Raper
authors.affiliation: School of Medicine, University of Virginia, Charlottesville, VA, USA.
authors.forename: Jordan R
authors.initials: JR
authors.lastname: Conger
authors.affiliation: Department of Radiology and Medical Imaging, University of Virginia, Post Office Box 800170, Charlottesville, VA 22908, USA. Electronic address: aje5u@virginia.edu.
authors.forename: Avery J
authors.initials: AJ
authors.lastname: Evans
mesh_terms: D000293:Adolescent; D000328:Adult; D002533:Cerebral Angiography; D016461:Chemoembolization, Therapeutic / Q000379:methods; D002648:Child; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011142:Polyvinyl Alcohol / Q000627:therapeutic use*; D016634:Radiosurgery / Q000379:methods; D012189:Retrospective Studies; D012597:Sclerosing Solutions / Q000627:therapeutic use*; D047011:Silk; D013537:Sutures; D016896:Treatment Outcome
chemical_list: D012597:Sclerosing Solutions; D047011:Silk; D011142:Polyvinyl Alcohol
keywords: Embolization; Gamma knife; Intracranial arteriovenous malformations; Particles; Radiosurgery; Silk; Stroke