title: Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes.
abstract: OBJECTIVE
  Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs.
  
  
  METHODS
  We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed.
  
  
  RESULTS
  A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months).
  
  
  CONCLUSIONS
  Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.
authors: School of Medicine, University of Virginia, Charlottesville, VA, USA.
authors: Jordan R
authors: JR
authors: Conger
authors: Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
authors: Dale
authors: 0000-0002-2627-446X
authors: D
authors: Ding
authors: Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
authors: Daniel M
authors: DM
authors: Raper
authors: Department of Neurological Surgery, University of Miami, Miami, FL, USA.
authors: Robert M
authors: RM
authors: Starke
authors: Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
authors: Christopher R
authors: CR
authors: Durst
authors: Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
authors: Kenneth C
authors: KC
authors: Liu
authors: Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
authors: Mary E
authors: ME
authors: Jensen
authors: Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
authors: Avery J
authors: AJ
authors: Evans
keywords: Endovascular procedures; Intracranial arteriovenous malformation; Intracranial hemorrhages; Microsurgery; Stroke; Vascular malformations