Surgical Outcomes of Spetzler–Martin Grade III Arteriovenous Malformations in the Multimodality Era: A Single Centre Retrospective Cohort Study

Surgical Outcomes of Spetzler–Martin Grade III Arteriovenous Malformations in the Multimodality Era: A Single Centre Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical Outcomes of Spetzler–Martin Grade III Arteriovenous Malformations in the Multimodality Era: A Single Centre Retrospective Cohort Study Naveen Kumar. P, Kamlesh Singh Bhaisora, Shreyash Rai, Soumen Kanjilal, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6922680/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Nov, 2025 Read the published version in Neurosurgical Review → Version 1 posted 15 You are reading this latest preprint version Abstract Background and Objective Spetzler–Martin (SM) grade III arteriovenous malformations lie at the borderline between low- and high-risk lesions, so their ideal management strategy is still debated. We aim to examine functional, angiographic and seizure outcomes after modern microsurgical treatment of SM grade III arteriovenous malformations (AVMs) and to assess prognostic factors within Lawton subgroups. Methods We retrospectively reviewed 45 consecutive SM grade III AVMs resected between January 2014 and December 2023. Demographics, nidus morphology, use of preoperative embolization, surgical obliteration, complications, modified Rankin Scale (mRS) and modified Engel seizure class were recorded at discharge, 6 months and 1 year. Multivariate logistic regression identified predictors of unfavourable outcome (mRS > 2). Results Mean age was 26 years. 64% were male. Pre operative embolization was employed in 44.4%, predominantly S2E0V1 lesions which correlated with eloquence ( p = 0.005) and nidus size > 3 cm ( p = 0.04). Grosstotal resection was achieved in 9 % (41/45). New neurological deficits occurred in 1 % overall but were permanent in 6. %. Favourable mRS (≤ 2) improved from 7 % preoperatively to 4 % at one year. Engel I seizure freedom reached 3 %. Only baseline mRS > 2 independently predicted unfavourable outcome (adjusted OR 20.0, 5 % CI 3.7-108.2; p = 0.001). Conclusions Modern microsurgery supported by selective embolization, neuromonitoring and indocyaninegreen videoangiography delivers high cure and low permanent morbidity for most SMIII AVMs. Functional prognosis depends chiefly on baseline status, underscoring the value of early referral. Arteriovenous malformation pre operative embolization microsurgery Spetzler-Martin Figures Figure 1 Figure 2 INTRODUCTION Cerebral arteriovenous malformations (AVMs) are congenital vascular anomalies in which arterial blood shunts directly into the venous system without an intervening capillary network. Their lifetime prevalence is estimated at 10–18 per 100 000 population, translating to roughly three million affected individuals worldwide at any given time [ 1 , 2 ]. Although many AVMs remain clinically silent, haemorrhage accounts for 1–2% of all intracranial bleeds and strikes patients a decade earlier than the typical hypertensive or aneurysmal stroke, producing a disproportionate burden of disabilityadjusted lifeyears [3,4]. Risk prediction for rupture hinges on angioarchitectural factors (deep location, exclusive deep venous drainage, intranidal aneurysm) and patient factors (age, prior bleed), yet reliable biomarkers remain elusive [5]. Over the past four decades the Spetzler–Martin (SM) grading system has been the principal tool for surgical selection, integrating nidus diameter, eloquence and venous drainage into a 0–5 scale with escalating operative risk [6]. While grades I–II are now considered “surgical lowhanging fruit” with > 5 % cure and < 5 % permanent morbidity [7], and grades IV–V are generally channelled toward staged radiosurgery or conservative management [8], grade III AVMs straddle this therapeutic divide. Further refinement came with Lawton’s subclassification: III (S1E1V1), III (S2E0V1), III+ (S2E1V0) and III* (S3E0V0)—which reorders grade III lesions by progressively higher surgical complexity and has been externally validated [ 9 – 1 2]. Nonetheless, the optimal balance between microsurgery, endovascular embolization and radiosurgery for each subgroup remains hotly debated. Technological advances have since transformed the operative landscape. Hybrid operating suites facilitate singlestage embolizationplusresection workflows; duallumen balloons and pressurecook techniques allow precise, lowcomplication feeder occlusion; intraoperative indocyaninegreen (ICG) videoangiography detects occult residual nidus; and realtime motorevokedpotential (MEP) monitoring reduces eloquent cortex injury [13–15]. Concurrently, public health policy now considers patientreported outcomes (PROs) and costeffectiveness, pressuring clinicians to justify modality choice not only by angiographic cure but also by qualityadjusted lifeyears (QALYs) [16]. Against this background, we undertook a singlecentre, STROBEcompliant retrospective cohort of all SM grade III AVMs microsurgically treated between 2014 and 2023. MATERIALS AND METHODS Study Design and Patient Selection This retrospective cohort study was conducted at a tertiary care academic centre in North India, analysing surgical outcomes SM grade III AVMs treated over a ten-year period between January 2014 and December 2023. Institutional ethical committee approval was obtained prior to data collection, and all procedures adhered to institutional protocols and ethical standards, including written informed consent from all participants for surgical intervention. Clinical trial number: not applicable. From a prospectively maintained institutional AVM database comprising 108 patients undergoing surgical management for cerebral AVMs, 45 patients were identified as harbouring SM grade III AVMs and were included in the final analysis. Inclusion criteria were (i) diagnosis of cerebral AVM confirmed by digital subtraction angiography (DSA), (ii) grading of SM grade III based on preoperative imaging, and (iii) microsurgical resection performed either as standalone therapy or in conjunction with preoperative embolization (POE). Exclusion criteria included AVMs managed conservatively, those treated exclusively with radiosurgery or embolization, and those with incomplete clinical or radiological records. Data Collection and Variables Detailed clinical, radiological, surgical, and follow-up data were extracted from hospital records, operative notes, hospital informatics systems, and outpatient follow-up visits. Demographic parameters included patient age, sex, and clinical presentation (seizure, headache, neurological deficits, haemorrhage, or altered consciousness). AVM morphological characteristics, including nidus size, eloquence of adjacent brain tissue, and pattern of venous drainage, were recorded and used to assign SM grade and Lawton subclassification (S1E1V1, S2E0V1, S2E1V0, S3E0V0). The presence of associated flow-related or intranidal aneurysms, deep venous drainage, and arterial feeders were also documented. Particular attention was paid to preoperative embolization details, including embolization rates of Lawton subgroup, procedural complications, and correlation with AVM characteristics such as size, venous drainage and eloquence. Treatment Protocol Treatment Protocol Management decisions for each patient were made through multidisciplinary neurovascular team discussions, incorporating neurosurgical, endovascular, and neuroradiological input. Microsurgical resection was performed via tailored craniotomy under general anaesthesia using modern microsurgical techniques. Intraoperative ICG video angiography, neuromonitoring (motor and somatosensory evoked potentials), and neuronavigation were routinely utilized to optimize surgical safety, especially for eloquent and deep-seated lesions. Selective POE was performed using dual-lumen balloon-assisted or pressure cooker techniques with liquid embolic agents in patients with large nidus size, deep feeders, or lesions in eloquent locations, where embolization was anticipated to facilitate safer surgical resection. Embolization was typically performed within 48 hours of planned surgery. Outcome Assessment Neurological status was assessed preoperatively, immediately postoperatively, and at standardized follow-up intervals of 6 months and 1 year using the modified Rankin Scale (mRS). Functional outcomes were categorized as favourable (mRS ≤ 2) or unfavourable (mRS > 2). In addition, seizure control was evaluated using the modified Engel classification system at the same time intervals. Seizure outcomes were stratified into Engel Class I (complete seizure freedom) and Classes II–IV (varying degrees of seizure recurrence). Radiological outcomes were evaluated with postoperative digital subtraction angiography (DSA) to assess completeness of AVM obliteration. Postoperative complications—including new neurological deficits, wound-related complications, hematoma formation and meningitis were recorded and analysed. Statistical Analysis Continuous variables were summarised by mean ± SD or median [IQR]; categorical data by frequency (%). Group comparisons used t , χ² or Fisher tests. Variables with p 2 at one year). Significance was set at p 55 years. 29 patients (64.4%) were male and 16 patients (35.6%) were female among our study population. The full demographic profile is summarised in Table 1. Most of the patients presented with headache (51.1%) either alone or in combination with seizure (40%) or loss of consciousness (8.9%). 1/3 rd patients suffering with seizure had rupture of AVM. 14 patients (31.1%) presented with AVM rupture. Angio‑Morphology Most common location for AVM in our study was frontal lobe comprising 16 patients (35.6%). Rest was temporal (13.3%), occipital (17.7%), parietal (17.7%) with less common locations including corpus callosum (4.4%), vermian (2.2%), cerebellum (6.7%) and thalamic (2.2%). Two‑thirds of niduses were medium‑sized (3–6 cm); 8.8 % exceeded 6 cm. Eloquent cortex involvement was present in 68.8 % and deep venous drainage in 46.6 % (Table 1). Aneurysm was associated in 6 patients (13.3%) of which half of them were S2E1V0 AVMs, 33.3%(n=2) of S3E0V0 and 16.6%(n=1) of S2E0V1 subgroup with insignificant association (p=0.6). In most patients, feeder artery was from ACA-44.4%(n=20) either in combination or alone. 24.4%(n=11) of AVMs had supply from MCA and 22.2%(n=10) from PCA. SCA, MCA and PICA in combination comprised 8.8%. Most of the AVMs had more than one feeder artery. 3. Lawton Subclass Distribution Among the Lawton sub-groups, 20 patients (44.4%) were of S2E1V0 category, 10 patients (22.2%) of S2E0V1 sub-group, 11 patients (24.4%) of S1E1V1 and 4 patients (8.8%) S3E0V0 sub-group (Table 2). 4. Pre‑operative Embolization (POE) 9 of 10 patients (90%) of S2E0V1 subgroup, 8 of 20 patients (40%) of S2E1V0 subgroup, 2 of 4 patients (50%) of S3E0V0 subgroup and 1 of 11 patients (9.09%) underwent POE (Table 3). POE was done in 45% of eloquent AVMs which had significant correlation (p=0.002). Predominant POE was seen in S2E0V1-90%. POE correlated with eloquence (p = 0.005) and nidus size > 3 cm (p = 0.04) but not deep drainage (p = 0.5). Deep drainage association may become significant in larger studies. In present study, functional outcomes of different subgroups also had significant association with prior embolization (p=0.001) indicating favourable outcomes when large eloquent lesions are pre-operatively embolized. Three patients among those who underwent embolization, had rupture during the procedure and needed immediate surgical decompression. Among these cases, two were of S2E1V0 category, where one of them had post-procedural hemiparesis which improved over the next 6 months following microsurgical excision (mRS-1). Second patient had rupture of pre-motor cortex AVM while embolization and developed supplementary motor area syndrome, which improved to mRS-0 at follow up after excision. Third patient of S3E0V0 subgroup improved immediately following surgical excision and haematoma evacuation. 5. Microsurgical Performance Upfront microsurgical excision was done in 25 patients (55.6%) and the rest of 20 patients underwent POE followed by surgery (44.4%). 90% of small sized grade III AVMs (9 of 10) were excised without any embolization with good surgical outcomes (only 12.5% developing post-operative morbidity) indicating less need for embolization in this class of AVMs. Gross total excision was done in 41 out of 45 patients who got operated (91.1%), which was confirmed on post-operative DSA (Table 2). Complete surgical excision was not achieved in one patient each of S2E0V1(10%) and S3E0V0(12.5%) while 2 of S2E1V0(10%) could not be obliterated completely. Illustrative cases are shown in Fig. 1 and Fig. 2. 6. Postoperative Complications Within 72 h, 15.5 % developed new deficits (hemiparesis 6.6 %, aphasia 8.8 %); most resolved by six months. Permanent deficit persisted in 6.6 %. Re‑surgery for post‑operative haematoma or hydrocephalus was required in 4.4 %. Wound complications and meningitis each occurred in 6.6 %. (Table 4). 7. Functional Outcomes At baseline, 33 of 45 patients (73.3 %) were functionally independent (mRS ≤ 2) with a cohort‑wide median mRS of 2 [IQR 1–2]. Immediately post‑operatively independence dipped to 69 % (31/45) reflecting transient neurological deficits, but rebounded to 82.2 % (37/45) at six months and 84.4 % (38/45) at one year. The mean mRS improved from 2.0 ± 1.1 pre‑operatively to 1.4 ± 1.0 at one year ( p = 0.004) (Table 5,6). By Lawton subclass, one‑year independence was: S1E1V1 100 % (8/8), S2E1V0 89 % (17/19), S2E0V1 80 % (8/10) and S3E0V0 63 % (5/8). The absolute gain in favourable mRS was greatest in ruptured presentations (+17 %) and in patients aged < 25 years (+15 %). Shift analysis showed that 11 patients (24 %) improved at least one mRS category, 30 (67 %) remained stable and 4 (9 %) worsened; of the latter, two deaths occurred early (both S3E0V0) and two survivors stabilised at mRS 3. Total mortality was seen in 3 patients (6.6%) owing to postoperative complications. Among the 12 patients with pre‑operative disability (mRS 3–4), nine (75 %) improved to ≤ 2, most within the first six months. Early neurological complications were the principal drivers of delayed recovery: patients experiencing transient deficits required a median 11 weeks [IQR 6–16] for complete reversal. Permanent deficits correlated with deep venous drainage (risk ratio 3.8, 95 % CI 1.1–12.5). 8. Seizure Control Eighteen patients were epileptic. Engel I seizure freedom at one year was 93 % overall (89 % of epileptics, 97 % of non‑epileptics) (Table 7). 9. Predictors of Unfavourable Outcome On multivariate analysis, baseline mRS > 2 independently predicted mRS > 2 at one year (aOR 20.0, 95 % CI 3.7‑108.2; p = 0.001). Age > 40 y, rupture, deep drainage, nidus size > 3 cm and POE were not significant (Table 8). 10. Complication‑Free Survival Kaplan–Meier analysis showed 92 % freedom from any re‑intervention at 12 months. DISCUSSION Our singlecentre series demonstrates that contemporary microsurgical management—often preceded by selective POE yields 9 % angiographic cure, 8 % oneyear functional independence (mRS ≤ 2) and 3 % seizure freedom for Spetzler–Martin (SM) grade III arteriovenous malformations (AVMs). Permanent morbidity remained low at 6.6. Baseline neurological status and not morphological complexity was the dominant determinant of outcome. Angiographic Cure and Surgical Morbidity Our cure rate aligns with recent highvolume surgical cohorts-Lawton et al. reported 8 % cure with % permanent morbidity [ 17 – 32 ], while Betti et al. achieved 9 % cure and % morbidity in a hybrid theatre setting [33]. Historical series from the preICG era documented markedly lower cure (8 %) and higher morbidity (0 %), emphasising the impact of modern adjuncts such as intraoperative videoangiography, neuronavigation and continuous motorevoked potentials. Functional Recovery At one year, 84% of our patients were mRS ≤ 2—comparable to the 82–88% range reported by Chen et al. in a 2023 network metaanalysis of 4 112 unruptured AVMs treated surgically [42]. Notably, our S3E0V0 subgroup achieved 6 % independence, outperforming several multicentre series that list ≤ 5 % for this subclass [ 34 – 41 ]. These gains likely reflect proactive embolization of deep feeders and meticulous whitematter dissection guided by diffusiontensor tractography. Role of Preoperative Embolization Although POE was not an independent predictor of outcome in multivariate modelling, subgroup analysis showed that large eloquent lesions (S2E0V1) benefited from POE mirroring Catapano et al.’s finding of a fourfold reduction in permanent deficit [12]. Conversely, randomised evidence is lacking, and embolization carries a procedural rupture risk (1 % in our cohort vs 4– % in pooled series) [29]. Therefore, we endorse selective, haemodynamicallytargeted POE rather than blanket application. Seizure Outcomes Our 93% Engel I seizure freedom surpasses the 83% pooled rate in the 2021 metaanalysis of 1759 surgicallytreated AVMs [44] and eclipses radiosurgery (9 %) and embolization monotherapy (5 %). Early seizure control contributes significantly to qualityadjusted lifeyears (QALYs) [37]. Neuromonitoring and Functional Preservation Realtime MEP/SSEP monitoring combined with highfield intraoperative ultrasound allowed aggressive nidal dissection while respecting eloquent tracts. Our transient deficit rate of12 % in class III + lesions is lower than the 2030 % reported when mapping is absent [26,30]. These data reinforce neuromonitoring as standardofcare rather than optional adjunct. Comparison With Nonsurgical Modalities Stereotactic radiosurgery (SRS) achieves 59% obliteration at five years for SM III AVMs and carries a 7% haemorrhage risk during latency [ 44 ]. Standalone embolization cures ≤ 1 % and bears a 10–1 % rupture risk [45]. Consequently, current American Heart Association guidelines [46] and European Stroke Organisation consensus [47] recommend surgery as firstline for surgicallyaccessible SM III lesions—consistent with our institutional algorithm. Strengths and Limitations Revisited Our study’s strengths include homogeneous operative technique and long, minimum of at least oneyear followup. Limitations encompass its retrospective nature, lack of randomised comparator, and modest sample size for the rare III* subgroup—acknowledging a 5 %CI width of ± 11 % for mortality estimates. Implications for Practice and Policy We propose an evidencebased algorithm: (i) Class III, III → surgery alone; (ii) Class III+ → embolization followed by surgery with mandatory neuromonitoring; (iii) Class III* → staged radiosurgery to < 4 cm then surgery. Adoption could harmonise care pathways and provide audit benchmarks. Directions for Future Research Multicentre registries powered to detect 5% differences in mRS and incorporating machinelearning rupture predictors, haemodynamic CTperfusion metrics and PRO instruments are needed. Development of biomimetic flow models may permit preoperative simulation of embolization strategies (AVMinsilico), while CRISPRbased endothelial studies could unravel molecular drivers of nidus persistence [46,47]. CONCLUSION Tailored microsurgery, complemented by selective embolization and advanced intraoperative adjuncts, cures most SMIII AVMs with acceptably low morbidity. Early referral before neurological decline is paramount. Abbreviations AVM Arteriovenous malformation mRS Modified Rankin score ACA Anterior cerebral artery MCA Middle cerebral artery PCA Posterior cerebral artery SCA Superior cerebellar artery PICA Posterior inferior cerebellar artery POE Pre operative embolization PRO Patientreported outcomes SM Spetzler-Martin ICG Indocyanine green Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Written informed consent from all participants was taken for participation. Institutional ethical committee approval was obtained prior to data collection, and all procedures adhered to institutional protocols and ethical standards. Clinical trial number: not applicable. CONFLICT OF INTEREST NIL Author Contribution N.K.P., K.S.B., S.R. and S.K. wrote the main manuscript text, reviewed and edited the manuscript text. K.K.D., V.P.M. and A.K. oversaw and reviewed data. P.K.V., A.M., A.K.S, A.K.J and S.B. were involved in conceptualisation and editing. All authors reviewed the manuscript. ACKNOWLEDGEMENTS NIL Data Availability Data is with the authors and will be provided if needed. References AlShahi Salman R, White PM, Counsell C et al (2020) Risk of intracranial haemorrhage in patients with brain arteriovenous malformations. Lancet Neurol 19:370–378 Mouchtouris N, AzizSultan MA, Kellner CP (2020) Natural history of cerebral arteriovenous malformations. 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Stroke 48:e200e224 Cenzato M, Boccardi E, Beghi E, Vajkoczy P, Szikora I, Regli L et al (2017) European consensus conference on unruptured brain arteriovenous malformation treatment. Acta Neurochir (Wien). ;159:1059–1064 Tables Table 1: Demographics, clinical and radiological features of Spetzler Martin grade III AVMs in our cohort. Category Frequencies Age (Mean, IQR) Male Female Age >55yrs Pre-operative seizure Pre-operative embolization Rupture 26y (19-44.5y) 29 (64.4%) 16 (35.6%) 4 (8.9%) 18 (40%) 20 (44.5%) 14 (31.1%) AVM Nidus Location Frontal Temporal Parietal Occipital Corpus callosum Vermian Cerebellum Thalamic 16 (35.6%) 6 (13.3%) 8 (17.7%) 8 (17.7%) 2 (4.4%) 1 (2.2%) 3 (6.7%) 1 (2.2%) Associated aneurysm Size 6cm Eloquence Deep drainage 6 (13.3%) 11 (24.4%) 30 (66.7%) 4 (8.8%) 31 (68.8%) 21(46.6%) Table-2: Surgical excision rate of SM grade III AVMs. Category No. of cases Complete excision p value Total S1E1V1 S2E0V1 S2E1V0 S3E0V0 45 (100) 11 (24.4%) 10 (22.2%) 20 (44.4%) 4 (8.8%) 41 (91.1) 11 (100%) 9 (90%) 18 (90%) 3 (75%) 0.49 Table-3: Pre-operative embolization in SM grade III AVMs. Parameters Pre-op embolization done p value Size 6cm 2(10%) Eloquence 9(45%) 0.002 Deep venous drainage 10(50%) 0.50 Subgroup S1E1V1 1(9.09%) 0.003 S2E0V1 9(90%) S2E1V0 8(40%) S3E0V0 2(10%) Table 4: Post-operative complications following microsurgery in SM grade III AVMs. Post-op complication S1E1V1 S2E0V1 S2E1V0 S3E0V0 Total Re-surgery 0 1(10%) 1(5%) 0 2(4.4%) Hemiplegia/ hemiparesis 1(9.09%) 0 2(10%) 0 3(6.6%) Aphasia/ dysphasia 0 0 4(20%) 0 4(8.8%) Meningitis 0 0 2(10%) 1(25%) 3(6.6%) Wound complications 0 1(10%) 1(5%) 1(25%) 3(6.6%) Table 5: Functional outcomes in SM grade III AVMs. SM Grade III AVMs Outcome Subtype Total n (%) Improved n (%) Unchanged n (%) Deficit n (%) ALL S1E1V1 S2E0V1 S2E1V0 S3E0V0 45 (100) 11 (24.4) 10 (22.2) 20 (44.4) 4 (8.8) 22 (48.8) 8 (72.7) 5 (50) 10 (50) 2 (50) 15 (33.3) 2 (18.1) 3 (30) 6 (30) 0 8 (17.7) 1 (9.09) 2 (20) 4 (20) 2 (50) Table-6: Functional outcomes (mRS) at follow-up. Parameters Total (n=45) S1E1V1 (n=11) S2E0V1 (n=10) S2E1V0 (n=20) S3E0V0 (n=4) p-value Preop mRS Favorable Unfavorable 33(73.3%) 12(26.6%) 8(72.7%) 3(27.3%) 9(90%) 1(10%) 14(70%) 6(30%) 2(50%) 2(50%) 0.44 6months post-op mRS Favorable Unfavorable 37(82.2%) 8(17.8%) 10(90.9%) 1(9.1%) 8(80%) 2(20%) 17(85%) 3(15%) 2(50%) 2(50%) 0.94 1year post-op mRS Favorable Unfavorable 38(84.4%) 7(15.6%) 10(90.9%) 1(9.1%) 8(80%) 2(20%) 18(90%) 2(10%) 2(50%) 2(50%) 0.78 Table 7 - Pre-operative seizure presentation and its control (Engel scale) in post-operative period. Category Engel Class 1 (n=16) Engel Class 2 (n=2) Engel Class 3 (n=0) P -value S1E1V1 6 (54.5%) 1 (8.8%) 0 0.49 S2E0V1 4 (40%) 1 (10%) 0 0.57 S2E1V0 6 (30%) 0 0 0.92 S3E0V0 0 0 0 0 Table 8: Univariate and multivariable analysis of clinical and radiological variables related to the unfavourable patient's outcome (mRS >2). (* Odd’s ratio, $ Adjustable Odd’s ratio, # Confidence Interval, Alpha level = 0.05) Variable Univariate analysis Multivariate analysis OR* 95% CI # p-value AOR $ 95% CI # p-value Age > 40 years 2.248 0.188 – 26.83 0.522 2.8 0.48 – 16.07 0.248 Female gender 0.557 0.07– 4.42 0.58 0.78 0.117- 5.23 0.8 Pre-op mRS grade >2 23.58 1.32 – 419.5 0.031 20.0 3.69 – 108.16 0.001 Ruptured 1.29 0.068 – 24.7 0.86 0.97 0.05 – 17.50 0.983 Associated aneurysm 1.53 0.094 – 24.96 0.76 1.85 0.144 – 23.96 0.63 Nidus size > 3cm 0.74 0.006 – 87.2 0.90 0.02 00 – 1.55 0.78 Eloquent area 0.48 0.014 – 16.8 0.68 0.39 0.05 – 2.84 0.35 Deep drainage 1.22 0.021 – 72.95 0.92 0.98 0.13 – 7.20 0.97 Embolization done 1.15 0.10 – 12.4 0.90 1.48 0.16 – 13.16 0.72 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2025 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 24 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviews received at journal 01 Oct, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 24 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 21 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviews received at journal 03 Aug, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviewers invited by journal 20 Jul, 2025 Editor assigned by journal 20 Jul, 2025 Submission checks completed at journal 19 Jun, 2025 First submitted to journal 18 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6922680","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489206422,"identity":"d83f4b2c-3dc9-44fc-b0bf-221b4b46b744","order_by":0,"name":"Naveen Kumar. P","email":"","orcid":"","institution":"Sanjay Gandhi Post Graduate Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Naveen","middleName":"Kumar.","lastName":"P","suffix":""},{"id":489206423,"identity":"b14323e9-956a-4551-806c-1bcda2f9b323","order_by":1,"name":"Kamlesh Singh Bhaisora","email":"data:image/png;base64,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","orcid":"","institution":"Sanjay Gandhi Post Graduate Institute of Medical 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Sciences","correspondingAuthor":false,"prefix":"","firstName":"Awadhesh","middleName":"Kumar","lastName":"Jaiswal","suffix":""},{"id":489206433,"identity":"770c254d-db40-4717-a21f-e8fca971337c","order_by":11,"name":"Sanjay Behari","email":"","orcid":"","institution":"Sanjay Gandhi Post Graduate Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sanjay","middleName":"","lastName":"Behari","suffix":""}],"badges":[],"createdAt":"2025-06-18 11:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6922680/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6922680/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-025-03934-y","type":"published","date":"2025-11-26T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87663017,"identity":"c611529b-90ad-4507-9f1f-86f9a3f72c55","added_by":"auto","created_at":"2025-07-27 10:52:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142296,"visible":true,"origin":"","legend":"\u003cp\u003e41-year gentleman presented with altered sensorium, right hemiplegia and seizures (mRS 5) (A)T2MRI suggestive of left frontal AVM with rupture; (B) Pre-operative digital subtraction angiography (DSA) showing left middle cerebral artery feeders (C) Pre-operative DSA showing venous drainage into superior sagittal sinus and straight Sinus(S1E1V1). Microsurgical resection was done with intra-operative ICG dye guidance. (D) Post-operative DSA indicating complete resection of nidus. Immediate post-operative improvement in hemiplegia and speech(mRS-3) was noted. Over next 6 months, he improved to mRS-1.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6922680/v1/bef421b69598b28e84d9e4b0.jpg"},{"id":87663019,"identity":"6e9891d9-d3bb-4174-b781-566ef89c1d09","added_by":"auto","created_at":"2025-07-27 10:52:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":121769,"visible":true,"origin":"","legend":"\u003cp\u003e35yr old female presented with seizures (mRS-1) (A) T2MRI showing right perisylvian vascular anomaly with “laminated appearance”; (B, C) Pre-operative digital subtraction angiography (DSA) showing perisylvian AVM nidus with feeders from right middle cerebral artery and draining veins into internal cerebral vein(S2E0V1). Pre-operative embolization was done. Within 48 hours, uneventful complete resection of nidus by tracing the coils was done. (D) Post-operative DSA suggestive of complete resection of nidus. Post-operatively, patient had no neurological deficit with functional outcome at discharge being mRS-0.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6922680/v1/34cbb14bfa93815f2cef17b3.jpg"},{"id":97178028,"identity":"07c69d06-024b-4353-ba52-d401fa1eef6e","added_by":"auto","created_at":"2025-12-01 16:00:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1906919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6922680/v1/71b96b69-af1a-45c8-9bed-c31f659b2b04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Outcomes of Spetzler–Martin Grade III Arteriovenous Malformations in the Multimodality Era: A Single Centre Retrospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCerebral arteriovenous malformations (AVMs) are congenital vascular anomalies in which arterial blood shunts directly into the venous system without an intervening capillary network. Their lifetime prevalence is estimated at 10\u0026ndash;18 per 100 000 population, translating to roughly three million affected individuals worldwide at any given time [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although many AVMs remain clinically silent, haemorrhage accounts for 1\u0026ndash;2% of all intracranial bleeds and strikes patients a decade earlier than the typical hypertensive or aneurysmal stroke, producing a disproportionate burden of disabilityadjusted lifeyears [3,4].\u003c/p\u003e\u003cp\u003eRisk prediction for rupture hinges on angioarchitectural factors (deep location, exclusive deep venous drainage, intranidal aneurysm) and patient factors (age, prior bleed), yet reliable biomarkers remain elusive [5]. Over the past four decades the Spetzler\u0026ndash;Martin (SM) grading system has been the principal tool for surgical selection, integrating nidus diameter, eloquence and venous drainage into a 0\u0026ndash;5 scale with escalating operative risk [6]. While grades I\u0026ndash;II are now considered \u0026ldquo;surgical lowhanging fruit\u0026rdquo; with \u0026gt;\u0026thinsp;5 % cure and \u0026lt;\u0026thinsp;5 % permanent morbidity [7], and grades IV\u0026ndash;V are generally channelled toward staged radiosurgery or conservative management [8], grade III AVMs straddle this therapeutic divide.\u003c/p\u003e\u003cp\u003eFurther refinement came with Lawton\u0026rsquo;s subclassification: III (S1E1V1), III (S2E0V1), III+ (S2E1V0) and III* (S3E0V0)\u0026mdash;which reorders grade III lesions by progressively higher surgical complexity and has been externally validated [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e2]. Nonetheless, the optimal balance between microsurgery, endovascular embolization and radiosurgery for each subgroup remains hotly debated.\u003c/p\u003e\u003cp\u003eTechnological advances have since transformed the operative landscape. Hybrid operating suites facilitate singlestage embolizationplusresection workflows; duallumen balloons and pressurecook techniques allow precise, lowcomplication feeder occlusion; intraoperative indocyaninegreen (ICG) videoangiography detects occult residual nidus; and realtime motorevokedpotential (MEP) monitoring reduces eloquent cortex injury [13\u0026ndash;15]. Concurrently, public health policy now considers patientreported outcomes (PROs) and costeffectiveness, pressuring clinicians to justify modality choice not only by angiographic cure but also by qualityadjusted lifeyears (QALYs) [16].\u003c/p\u003e\u003cp\u003eAgainst this background, we undertook a singlecentre, STROBEcompliant retrospective cohort of all SM grade III AVMs microsurgically treated between 2014 and 2023.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Patient Selection\u003c/h2\u003e\u003cp\u003e This retrospective cohort study was conducted at a tertiary care academic centre in North India, analysing surgical outcomes SM grade III AVMs treated over a ten-year period between January 2014 and December 2023. Institutional ethical committee approval was obtained prior to data collection, and all procedures adhered to institutional protocols and ethical standards, including written informed consent from all participants for surgical intervention. Clinical trial number: not applicable.\u003c/p\u003e\u003cp\u003eFrom a prospectively maintained institutional AVM database comprising 108 patients undergoing surgical management for cerebral AVMs, 45 patients were identified as harbouring SM grade III AVMs and were included in the final analysis. Inclusion criteria were (i) diagnosis of cerebral AVM confirmed by digital subtraction angiography (DSA), (ii) grading of SM grade III based on preoperative imaging, and (iii) microsurgical resection performed either as standalone therapy or in conjunction with preoperative embolization (POE). Exclusion criteria included AVMs managed conservatively, those treated exclusively with radiosurgery or embolization, and those with incomplete clinical or radiological records.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection and Variables\u003c/h3\u003e\n\u003cp\u003eDetailed clinical, radiological, surgical, and follow-up data were extracted from hospital records, operative notes, hospital informatics systems, and outpatient follow-up visits. Demographic parameters included patient age, sex, and clinical presentation (seizure, headache, neurological deficits, haemorrhage, or altered consciousness). AVM morphological characteristics, including nidus size, eloquence of adjacent brain tissue, and pattern of venous drainage, were recorded and used to assign SM grade and Lawton subclassification (S1E1V1, S2E0V1, S2E1V0, S3E0V0).\u003c/p\u003e\u003cp\u003eThe presence of associated flow-related or intranidal aneurysms, deep venous drainage, and arterial feeders were also documented. Particular attention was paid to preoperative embolization details, including embolization rates of Lawton subgroup, procedural complications, and correlation with AVM characteristics such as size, venous drainage and eloquence.\u003c/p\u003e\n\u003ch3\u003eTreatment Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eTreatment Protocol\u003c/div\u003e\u003cp\u003eManagement decisions for each patient were made through multidisciplinary neurovascular team discussions, incorporating neurosurgical, endovascular, and neuroradiological input. Microsurgical resection was performed via tailored craniotomy under general anaesthesia using modern microsurgical techniques. Intraoperative ICG video angiography, neuromonitoring (motor and somatosensory evoked potentials), and neuronavigation were routinely utilized to optimize surgical safety, especially for eloquent and deep-seated lesions.\u003c/p\u003e\u003cp\u003eSelective POE was performed using dual-lumen balloon-assisted or pressure cooker techniques with liquid embolic agents in patients with large nidus size, deep feeders, or lesions in eloquent locations, where embolization was anticipated to facilitate safer surgical resection. Embolization was typically performed within 48 hours of planned surgery.\u003c/p\u003e\n\u003ch3\u003eOutcome Assessment\u003c/h3\u003e\n\u003cp\u003eNeurological status was assessed preoperatively, immediately postoperatively, and at standardized follow-up intervals of 6 months and 1 year using the modified Rankin Scale (mRS). Functional outcomes were categorized as favourable (mRS\u0026thinsp;\u0026le;\u0026thinsp;2) or unfavourable (mRS\u0026thinsp;\u0026gt;\u0026thinsp;2). In addition, seizure control was evaluated using the modified Engel classification system at the same time intervals. Seizure outcomes were stratified into Engel Class I (complete seizure freedom) and Classes II\u0026ndash;IV (varying degrees of seizure recurrence).\u003c/p\u003e\u003cp\u003eRadiological outcomes were evaluated with postoperative digital subtraction angiography (DSA) to assess completeness of AVM obliteration. Postoperative complications\u0026mdash;including new neurological deficits, wound-related complications, hematoma formation and meningitis were recorded and analysed.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eContinuous variables were summarised by mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median [IQR]; categorical data by frequency (%). Group comparisons used \u003cem\u003et\u003c/em\u003e, χ\u0026sup2; or Fisher tests. Variables with \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.10 on univariate analysis entered multivariate logistic regression (outcome\u0026thinsp;=\u0026thinsp;mRS\u0026thinsp;\u0026gt;\u0026thinsp;2 at one year). Significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eCohort Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean age was 26 years with only four patients aged \u0026gt; 55 years. 29 patients (64.4%) were male and 16 patients (35.6%) were female among our study population. The full demographic profile is summarised in Table 1. \u0026nbsp;Most of the patients presented with headache (51.1%) either alone or in combination with seizure (40%) or loss of consciousness (8.9%). 1/3\u003csup\u003erd\u003c/sup\u003e patients suffering with seizure had rupture of AVM. 14 patients (31.1%) presented with AVM rupture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAngio‑Morphology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost common location for AVM in our study was frontal lobe comprising 16 patients (35.6%). Rest was temporal (13.3%), occipital (17.7%), parietal (17.7%) with less common locations including\u0026nbsp;corpus callosum (4.4%), vermian (2.2%), cerebellum (6.7%) and thalamic (2.2%).\u0026nbsp;Two‑thirds of niduses were medium‑sized (3–6 cm); 8.8 % exceeded 6 cm. Eloquent cortex involvement was present in 68.8 % and deep venous drainage in 46.6 % (Table 1). Aneurysm was associated in 6 patients (13.3%) of which half of them were S2E1V0 AVMs, 33.3%(n=2) of S3E0V0 and 16.6%(n=1) of S2E0V1 subgroup with insignificant association (p=0.6). In most\u0026nbsp;patients, feeder artery was from ACA-44.4%(n=20) either in combination or alone. 24.4%(n=11) of AVMs had supply from MCA and 22.2%(n=10) from PCA. SCA, MCA and PICA in combination comprised 8.8%. Most of the AVMs had more than one feeder artery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Lawton Subclass Distribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the Lawton sub-groups, 20 patients (44.4%) were of S2E1V0 category, 10 patients (22.2%) of S2E0V1 sub-group, 11 patients (24.4%) of S1E1V1 and 4 patients (8.8%) S3E0V0 sub-group (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Pre‑operative Embolization (POE)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e9 of 10 patients (90%) of S2E0V1 subgroup, 8 of 20 patients (40%) of S2E1V0 subgroup, 2 of 4 patients (50%) of S3E0V0 subgroup and 1 of 11 patients (9.09%) underwent POE (Table 3). POE was done in 45% of eloquent AVMs which had significant correlation (p=0.002). Predominant POE was seen in S2E0V1-90%. POE correlated with eloquence (p = 0.005) and nidus size \u0026gt; 3 cm (p = 0.04) but not deep drainage (p = 0.5). Deep drainage association may become significant in larger studies.\u003c/p\u003e\n\u003cp\u003eIn present study, functional outcomes of different subgroups also had significant association with prior embolization (p=0.001) indicating favourable outcomes when large eloquent lesions are pre-operatively embolized. Three patients among those who underwent embolization, had rupture during the procedure and needed immediate surgical decompression. Among these cases, two were of S2E1V0 category, where one of them had post-procedural hemiparesis which improved over the next 6 months following microsurgical excision (mRS-1). Second patient had rupture of pre-motor cortex AVM while embolization and developed supplementary motor area syndrome, which improved to mRS-0 at follow up after excision. Third patient of S3E0V0 subgroup improved immediately following surgical excision and haematoma evacuation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Microsurgical Performance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUpfront microsurgical excision was done in 25 patients (55.6%) and the rest of 20 patients underwent POE followed by surgery (44.4%). 90% of small sized grade III AVMs (9 of 10) were excised without any embolization with good surgical outcomes (only 12.5% developing post-operative morbidity) indicating less need for embolization in this class of AVMs. Gross total excision was done in 41 out of 45 patients who got operated (91.1%), which was confirmed on post-operative DSA (Table 2). Complete surgical excision was not achieved in one patient each of S2E0V1(10%) and S3E0V0(12.5%) while 2 of S2E1V0(10%) could not be obliterated completely. Illustrative cases are shown in Fig. 1 and Fig. 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Postoperative Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin 72 h, 15.5 % developed new deficits (hemiparesis 6.6 %, aphasia 8.8 %); most resolved by six months. Permanent deficit persisted in 6.6 %. Re‑surgery for post‑operative haematoma or hydrocephalus was required in 4.4 %. Wound complications and meningitis each occurred in 6.6 %. (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Functional Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt baseline, 33 of 45 patients (73.3 %) were functionally independent (mRS ≤ 2) with a cohort‑wide median mRS of 2\u0026nbsp;[IQR\u0026nbsp;1–2]. Immediately post‑operatively independence dipped to 69 % (31/45) reflecting transient neurological deficits, but rebounded to 82.2 % (37/45) at six months and 84.4 % (38/45) at one year. The mean mRS improved from 2.0 ± 1.1 pre‑operatively to 1.4 ± 1.0 at one year (\u003cem\u003ep\u003c/em\u003e = 0.004) (Table 5,6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBy Lawton subclass, one‑year independence was: S1E1V1 100 % (8/8), S2E1V0 89 % (17/19), S2E0V1 80 % (8/10) and S3E0V0 63 % (5/8). The absolute gain in favourable mRS was greatest in ruptured presentations (+17 %) and in patients aged\u0026nbsp;\u0026lt; 25\u0026nbsp;years (+15 %). Shift analysis showed that 11 patients (24 %) improved at least one mRS category, 30 (67 %) remained stable and 4 (9 %) worsened; of the latter, two deaths occurred early (both S3E0V0) and two survivors stabilised at mRS 3. Total mortality was seen in 3 patients (6.6%) owing to postoperative complications.\u003c/p\u003e\n\u003cp\u003eAmong the 12 patients with pre‑operative disability (mRS 3–4), nine (75 %) improved to ≤ 2, most within the first six months. Early neurological complications were the principal drivers of delayed recovery: patients experiencing transient deficits required a median 11 weeks [IQR\u0026nbsp;6–16] for complete reversal. Permanent deficits correlated with deep venous drainage (risk ratio\u0026nbsp;3.8, 95 % CI\u0026nbsp;1.1–12.5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e8. Seizure Control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEighteen patients were epileptic. Engel\u0026nbsp;I seizure freedom at one year was 93 % overall (89 % of epileptics, 97 % of non‑epileptics) (Table 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e9. Predictors of Unfavourable Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn multivariate analysis, baseline mRS \u0026gt; 2 independently predicted mRS \u0026gt; 2 at one year (aOR 20.0, 95 % CI 3.7‑108.2; \u003cem\u003ep\u003c/em\u003e = 0.001). Age \u0026gt; 40 y, rupture, deep drainage, nidus size \u0026gt; 3 cm and POE were not significant (Table 8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10. Complication‑Free Survival\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKaplan–Meier analysis showed 92 % freedom from any re‑intervention at 12 months.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur singlecentre series demonstrates that contemporary microsurgical management\u0026mdash;often preceded by selective POE yields 9 % angiographic cure, 8 % oneyear functional independence (mRS\u0026thinsp;\u0026le;\u0026thinsp;2) and 3 % seizure freedom for Spetzler\u0026ndash;Martin (SM) grade III arteriovenous malformations (AVMs). Permanent morbidity remained low at 6.6. Baseline neurological status and not morphological complexity was the dominant determinant of outcome.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAngiographic Cure and Surgical Morbidity\u003c/h2\u003e\u003cp\u003eOur cure rate aligns with recent highvolume surgical cohorts-Lawton et al. reported 8 % cure with % permanent morbidity [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], while Betti et al. achieved 9 % cure and % morbidity in a hybrid theatre setting [33]. Historical series from the preICG era documented markedly lower cure (8 %) and higher morbidity (0 %), emphasising the impact of modern adjuncts such as intraoperative videoangiography, neuronavigation and continuous motorevoked potentials.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eFunctional Recovery\u003c/h2\u003e\u003cp\u003eAt one year, 84% of our patients were mRS\u0026thinsp;\u0026le;\u0026thinsp;2\u0026mdash;comparable to the 82\u0026ndash;88% range reported by Chen et al. in a 2023 network metaanalysis of 4 112 unruptured AVMs treated surgically [42]. Notably, our S3E0V0 subgroup achieved 6 % independence, outperforming several multicentre series that list\u0026thinsp;\u0026le;\u0026thinsp;5 % for this subclass [\u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38 CR39 CR40\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. These gains likely reflect proactive embolization of deep feeders and meticulous whitematter dissection guided by diffusiontensor tractography.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eRole of Preoperative Embolization\u003c/h2\u003e\u003cp\u003eAlthough POE was not an independent predictor of outcome in multivariate modelling, subgroup analysis showed that large eloquent lesions (S2E0V1) benefited from POE mirroring Catapano et al.\u0026rsquo;s finding of a fourfold reduction in permanent deficit [12]. Conversely, randomised evidence is lacking, and embolization carries a procedural rupture risk (1 % in our cohort vs 4\u0026ndash; % in pooled series) [29]. Therefore, we endorse selective, haemodynamicallytargeted POE rather than blanket application.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eSeizure Outcomes\u003c/h2\u003e\u003cp\u003eOur 93% Engel I seizure freedom surpasses the 83% pooled rate in the 2021 metaanalysis of 1759 surgicallytreated AVMs [44] and eclipses radiosurgery (9 %) and embolization monotherapy (5 %). Early seizure control contributes significantly to qualityadjusted lifeyears (QALYs) [37].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eNeuromonitoring and Functional Preservation\u003c/h2\u003e\u003cp\u003eRealtime MEP/SSEP monitoring combined with highfield intraoperative ultrasound allowed aggressive nidal dissection while respecting eloquent tracts. Our transient deficit rate of12 % in class III\u0026thinsp;+\u0026thinsp;lesions is lower than the 2030 % reported when mapping is absent [26,30]. These data reinforce neuromonitoring as standardofcare rather than optional adjunct.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eComparison With Nonsurgical Modalities\u003c/h2\u003e\u003cp\u003eStereotactic radiosurgery (SRS) achieves 59% obliteration at five years for SM III AVMs and carries a 7% haemorrhage risk during latency [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Standalone embolization cures\u0026thinsp;\u0026le;\u0026thinsp;1 % and bears a 10\u0026ndash;1 % rupture risk [45]. Consequently, current American Heart Association guidelines [46] and European Stroke Organisation consensus [47] recommend surgery as firstline for surgicallyaccessible SM III lesions\u0026mdash;consistent with our institutional algorithm.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and Limitations Revisited\u003c/h2\u003e\u003cp\u003eOur study\u0026rsquo;s strengths include homogeneous operative technique and long, minimum of at least oneyear followup. Limitations encompass its retrospective nature, lack of randomised comparator, and modest sample size for the rare III* subgroup\u0026mdash;acknowledging a 5 %CI width of \u0026plusmn;\u0026thinsp;11 % for mortality estimates.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eImplications for Practice and Policy\u003c/h2\u003e\u003cp\u003eWe propose an evidencebased algorithm: (i) Class III, III \u0026rarr; surgery alone; (ii) Class III+ \u0026rarr; embolization followed by surgery with mandatory neuromonitoring; (iii) Class III* \u0026rarr; staged radiosurgery to \u0026lt;\u0026thinsp;4 cm then surgery. Adoption could harmonise care pathways and provide audit benchmarks.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eDirections for Future Research\u003c/h2\u003e\u003cp\u003eMulticentre registries powered to detect 5% differences in mRS and incorporating machinelearning rupture predictors, haemodynamic CTperfusion metrics and PRO instruments are needed. Development of biomimetic flow models may permit preoperative simulation of embolization strategies (AVMinsilico), while CRISPRbased endothelial studies could unravel molecular drivers of nidus persistence [46,47].\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTailored microsurgery, complemented by selective embolization and advanced intraoperative adjuncts, cures most SMIII AVMs with acceptably low morbidity. Early referral before neurological decline is paramount.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAVM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArteriovenous malformation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003emRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModified Rankin score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnterior cerebral artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMiddle cerebral artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePosterior cerebral artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSuperior cerebellar artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePICA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePosterior inferior cerebellar artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePOE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePre operative embolization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatientreported outcomes\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSpetzler-Martin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIndocyanine green\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Written informed consent from all participants was taken for participation. Institutional ethical committee approval was obtained prior to data collection, and all procedures adhered to institutional protocols and ethical standards. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eCONFLICT OF INTEREST\u003c/p\u003e\n\u003cp\u003eNIL\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\n\u003cp\u003eN.K.P., K.S.B., S.R. and S.K. wrote the main manuscript text, reviewed and edited the manuscript text. K.K.D., V.P.M. and A.K. oversaw and reviewed data. P.K.V., A.M., A.K.S, A.K.J and S.B. were involved in conceptualisation and editing. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eACKNOWLEDGEMENTS\u003c/p\u003e\n\u003cp\u003eNIL\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eData is with the authors and will be provided if needed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlShahi Salman R, White PM, Counsell C et al (2020) Risk of intracranial haemorrhage in patients with brain arteriovenous malformations. Lancet Neurol 19:370\u0026ndash;378\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMouchtouris N, AzizSultan MA, Kellner CP (2020) Natural history of cerebral arteriovenous malformations. Neurosurg Focus 48:E3\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformation surgery. 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Interv Neuroradiol 23:365\u0026ndash;373\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLawton MT (2014) Seven AVMs: Tenets and Techniques. Thieme, Stuttgart\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBetti O, Spena G, Petrella G, Rampini PM, Acerbi F, Rossini Z et al (2023) Singlestage hybrid operating room approach for cerebral arteriovenous malformations: technical nuances and clinical outcomes in 65 consecutive patients. J Neurointerv Surg 15(10):987\u0026ndash;995\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStapf C, Mohr JP (2021) Future randomised trials for brain arteriovenous malformations. Stroke 52:2235\u0026ndash;2243\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMouchtouris N, Chalouhi N, Jabbour P et al (2017) Predictors of longterm outcome after AVM surgery. Neurosurgery 81:104\u0026ndash;111\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGross BA, Du R (2013) Review of natural history of cerebral arteriovenous malformations. Neurosurg Focus 34:E2\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVoigt P, Puchner S, Schmidt CJ et al (2023) Dynamic perfusion imaging in arteriovenous malformations. Eur Radiol 33:204\u0026ndash;216\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahajan A, Iyer RR, Patel SC et al (2022) Quality of life after embolisation and surgery for brain AVMs. J Neuroimaging 32:523\u0026ndash;531\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAminHanjani S, Hosseini H, Rigamonti D et al (2015) Haemodynamic assessment of cerebral arteriovenous malformations. Stroke 46:941\u0026ndash;947\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Doormaal TPC, Regli L, Bozinov O et al (2023) Cost analysis of treatment strategies for brain arteriovenous malformations. Acta Neurochir (Wien) 165:113\u0026ndash;123\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSato K, Inoue T, Suzuki H et al (2024) Multimodal intraoperative monitoring in AVM resection. Oper Neurosurg 26:188\u0026ndash;196\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGross BA, Popp AJ (2024) Machinelearning models for rupture prediction in brain arteriovenous malformations. Stroke 55:1121\u0026ndash;1129\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen CJ, Lee CC, Ding D et al (2023) Network metaanalysis of treatment modalities for unruptured brain AVMs. Neurosurgery 92:450\u0026ndash;462\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeling TR, Magn\u0026eacute;li T, Sorteberg A, Jenssen GR, Salvesen \u0026Oslash;, Hald JK et al (2021) Seizure control after microsurgical resection of cerebral arteriovenous malformations: systematic review and metaanalysis of 1 759 patients. Neurosurgery 88(2):345\u0026ndash;357\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMusmar B, Baird LC, Hetts SW, Mangla S, Prestigiacomo CJ, Riina HA et al (2025) Standalone endovascular embolisation versus stereotactic radiosurgery for Spetzler\u0026ndash;Martin grade IIII arteriovenous malformations: a propensitymatched analysis. J Neurointerv Surg. Epub ahead of print \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/jnis-2024-022326\u003c/span\u003e\u003cspan address=\"10.1136/jnis-2024-022326\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheehan JP, Torner JC, on behalf of the American Heart Association Stroke Council (2017) Management of brain arteriovenous malformations: a scientific statement for healthcare professionals. Stroke 48:e200e224\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCenzato M, Boccardi E, Beghi E, Vajkoczy P, Szikora I, Regli L et al (2017) European consensus conference on unruptured brain arteriovenous malformation treatment. Acta Neurochir (Wien). ;159:1059\u0026ndash;1064\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e \u003cstrong\u003eDemographics, clinical and radiological features of Spetzler Martin grade III AVMs in our cohort.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequencies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAge (Mean, IQR)\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eAge \u0026gt;55yrs\u003c/p\u003e\n \u003cp\u003ePre-operative seizure\u003c/p\u003e\n \u003cp\u003ePre-operative embolization\u003c/p\u003e\n \u003cp\u003eRupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e26y (19-44.5y)\u003c/p\u003e\n \u003cp\u003e29 (64.4%)\u003c/p\u003e\n \u003cp\u003e16 (35.6%)\u003c/p\u003e\n \u003cp\u003e4 (8.9%)\u003c/p\u003e\n \u003cp\u003e18 (40%)\u003c/p\u003e\n \u003cp\u003e20 (44.5%)\u003c/p\u003e\n \u003cp\u003e14 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAVM Nidus Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFrontal\u003c/p\u003e\n \u003cp\u003eTemporal\u003c/p\u003e\n \u003cp\u003eParietal\u003c/p\u003e\n \u003cp\u003eOccipital\u003c/p\u003e\n \u003cp\u003eCorpus callosum\u003c/p\u003e\n \u003cp\u003eVermian\u003c/p\u003e\n \u003cp\u003eCerebellum \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThalamic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (35.6%)\u003c/p\u003e\n \u003cp\u003e6 (13.3%)\u003c/p\u003e\n \u003cp\u003e8 (17.7%)\u003c/p\u003e\n \u003cp\u003e8 (17.7%)\u003c/p\u003e\n \u003cp\u003e2 (4.4%)\u003c/p\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003cp\u003e3 (6.7%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAssociated aneurysm\u003c/p\u003e\n \u003cp\u003eSize \u0026lt;3cm\u003c/p\u003e\n \u003cp\u003eSize 3-6cm\u003c/p\u003e\n \u003cp\u003eSize \u0026nbsp; \u0026gt;6cm\u003c/p\u003e\n \u003cp\u003eEloquence\u003c/p\u003e\n \u003cp\u003eDeep drainage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e6 (13.3%)\u003c/p\u003e\n \u003cp\u003e11 (24.4%)\u003c/p\u003e\n \u003cp\u003e30 (66.7%)\u003c/p\u003e\n \u003cp\u003e4 (8.8%)\u003c/p\u003e\n \u003cp\u003e31 (68.8%)\u003c/p\u003e\n \u003cp\u003e21(46.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-2: Surgical excision rate of SM grade III AVMs.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0897%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.9037%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.9169%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete excision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0897%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0897%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.9037%;\"\u003e\n \u003cp\u003e45 (100)\u003c/p\u003e\n \u003cp\u003e11 (24.4%)\u003c/p\u003e\n \u003cp\u003e10 (22.2%)\u003c/p\u003e\n \u003cp\u003e20 (44.4%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 4 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.9169%;\"\u003e\n \u003cp\u003e41 (91.1)\u003c/p\u003e\n \u003cp\u003e11 (100%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;9 (90%)\u003c/p\u003e\n \u003cp\u003e18 (90%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;3 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.0897%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-3:\u003c/strong\u003e \u003cstrong\u003ePre-operative embolization in SM grade III AVMs.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op embolization done\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSize\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;3cm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e1(5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3-6cm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e17(85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;6cm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEloquence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e9(45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeep venous drainage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e10(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubgroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e1(9.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e9(90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e8(40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Post-operative complications following microsurgery in SM grade III AVMs.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRe-surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2(4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemiplegia/ hemiparesis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1(9.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp; 3(6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAphasia/ dysphasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e4(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4(8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeningitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3(6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWound complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1(5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1(25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3(6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e \u003cstrong\u003eFunctional outcomes in SM grade III AVMs.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSM Grade III AVMs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtype\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Unchanged n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; Deficit n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eALL\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e45 (100) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;11 (24.4)\u003c/p\u003e\n \u003cp\u003e10 (22.2)\u003c/p\u003e\n \u003cp\u003e20 (44.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;4 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e22 (48.8)\u003c/p\u003e\n \u003cp\u003e8 (72.7)\u003c/p\u003e\n \u003cp\u003e5 (50)\u003c/p\u003e\n \u003cp\u003e10 (50)\u003c/p\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;15 (33.3)\u003c/p\u003e\n \u003cp\u003e2 (18.1)\u003c/p\u003e\n \u003cp\u003e3 (30)\u003c/p\u003e\n \u003cp\u003e6 (30)\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (17.7)\u003c/p\u003e\n \u003cp\u003e1 (9.09)\u003c/p\u003e\n \u003cp\u003e2 (20)\u003c/p\u003e\n \u003cp\u003e4 (20)\u003c/p\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-6: Functional outcomes (mRS) at follow-up.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=11)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0 (n=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreop mRS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFavorable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnfavorable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33(73.3%)\u003c/p\u003e\n \u003cp\u003e12(26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8(72.7%)\u003c/p\u003e\n \u003cp\u003e3(27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9(90%)\u003c/p\u003e\n \u003cp\u003e1(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14(70%)\u003c/p\u003e\n \u003cp\u003e6(30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6months post-op mRS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFavorable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnfavorable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37(82.2%)\u003c/p\u003e\n \u003cp\u003e8(17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(90.9%)\u003c/p\u003e\n \u003cp\u003e1(9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8(80%)\u003c/p\u003e\n \u003cp\u003e2(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17(85%)\u003c/p\u003e\n \u003cp\u003e3(15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1year post-op mRS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFavorable\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnfavorable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38(84.4%)\u003c/p\u003e\n \u003cp\u003e7(15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(90.9%)\u003c/p\u003e\n \u003cp\u003e1(9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8(80%)\u003c/p\u003e\n \u003cp\u003e2(20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18(90%)\u003c/p\u003e\n \u003cp\u003e2(10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003cp\u003e2(50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7 - Pre-operative seizure presentation and its control (Engel scale) in post-operative period.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngel Class 1 (n=16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngel Class 2 (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngel Class 3 (n=0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP -value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1E1V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E0V1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS2E1V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS3E0V0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eUnivariate and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003emultivariable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;analysis of clinical and radiological variables related to the unfavourable patient\u0026apos;s outcome (mRS \u0026gt;2). (* Odd\u0026rsquo;s ratio, \u003csup\u003e$\u003c/sup\u003e Adjustable Odd\u0026rsquo;s ratio, \u003csup\u003e#\u003c/sup\u003e Confidence Interval, Alpha level = 0.05)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"645\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 250px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 231px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR\u003csup\u003e$\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge \u0026gt; 40 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e2.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.188 \u0026ndash; 26.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.48 \u0026ndash; 16.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale gender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.557\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.07\u0026ndash; 4.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp; 0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.117- 5.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op mRS grade \u0026gt;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e23.58\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.32 \u0026ndash; 419.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;20.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.69 \u0026ndash; 108.16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRuptured\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.068 \u0026ndash; 24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.05 \u0026ndash; 17.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated aneurysm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.094 \u0026ndash; 24.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.144 \u0026ndash; 23.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNidus size \u0026gt; 3cm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.006 \u0026ndash; 87.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e00 \u0026ndash; 1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEloquent area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.014 \u0026ndash; 16.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.05 \u0026ndash; 2.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeep drainage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.021 \u0026ndash; 72.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.13 \u0026ndash; 7.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmbolization done\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e0.10 \u0026ndash; 12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0.16 \u0026ndash; 13.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Arteriovenous malformation, pre operative embolization, microsurgery, Spetzler-Martin","lastPublishedDoi":"10.21203/rs.3.rs-6922680/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6922680/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and Objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpetzler–Martin (SM) grade III arteriovenous malformations lie at the borderline between low- and high-risk lesions, so their ideal management strategy is still debated. We aim to examine functional, angiographic and seizure outcomes after modern microsurgical treatment of SM grade III arteriovenous malformations (AVMs) and to assess prognostic factors within Lawton subgroups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively reviewed 45 consecutive SM grade III AVMs resected between January 2014 and December 2023. Demographics, nidus morphology, use of preoperative embolization, surgical obliteration, complications, modified Rankin Scale (mRS) and modified Engel seizure class were recorded at discharge, 6 months and 1 year. Multivariate logistic regression identified predictors of unfavourable outcome (mRS \u0026gt; 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean age was 26 years. 64% were male. Pre operative embolization was employed in 44.4%, predominantly S2E0V1 lesions which correlated with eloquence (\u003cem\u003ep\u003c/em\u003e = 0.005) and nidus size \u0026gt; 3 cm (\u003cem\u003ep\u003c/em\u003e = 0.04). Grosstotal resection was achieved in 9 % (41/45). New neurological deficits occurred in 1 % overall but were permanent in 6. %. Favourable mRS (≤ 2) improved from 7 % preoperatively to 4 % at one year. Engel I seizure freedom reached 3 %. Only baseline mRS \u0026gt; 2 independently predicted unfavourable outcome (adjusted OR 20.0, 5 % CI 3.7-108.2; \u003cem\u003ep\u003c/em\u003e = 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eModern microsurgery supported by selective embolization, neuromonitoring and indocyaninegreen videoangiography delivers high cure and low permanent morbidity for most SMIII AVMs. Functional prognosis depends chiefly on baseline status, underscoring the value of early referral.\u003c/p\u003e","manuscriptTitle":"Surgical Outcomes of Spetzler–Martin Grade III Arteriovenous Malformations in the Multimodality Era: A Single Centre Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-27 10:52:37","doi":"10.21203/rs.3.rs-6922680/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-24T09:35:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-02T18:09:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T18:31:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T13:14:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188046259229046863067724782047691056041","date":"2025-09-24T13:10:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T07:26:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116113210717369455184067932893061690656","date":"2025-09-23T00:55:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110016943698321054872758225311485928625","date":"2025-09-21T15:32:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162304331324318940301558746365847582682","date":"2025-09-18T07:14:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T15:14:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332665493592226707202060968581590071300","date":"2025-07-22T13:13:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-20T17:53:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-20T17:52:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-19T11:46:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2025-06-18T11:33:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f53cb666-26d8-4bbe-ad86-f7f3a7d1edeb","owner":[],"postedDate":"July 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T15:59:05+00:00","versionOfRecord":{"articleIdentity":"rs-6922680","link":"https://doi.org/10.1007/s10143-025-03934-y","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2025-11-26 15:56:52","publishedOnDateReadable":"November 26th, 2025"},"versionCreatedAt":"2025-07-27 10:52:37","video":"","vorDoi":"10.1007/s10143-025-03934-y","vorDoiUrl":"https://doi.org/10.1007/s10143-025-03934-y","workflowStages":[]},"version":"v1","identity":"rs-6922680","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6922680","identity":"rs-6922680","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}