Multimodal Management of a Ruptured Right Medial Parietal Arteriovenous Malformation: 2-Dimensional Operative Video

Arteriovenous malformations (AVM) of the medial surface of the cerebral hemispheres are challenging because of the limited access to the interhemispheric fissure, the presence of the bridging veins, and the difficult control of arterial feeders and deep venous drainage. We present a 20-yr-old patient with a grade 3 Spetzler Martin ruptured right medial parietal AVM revealed by headaches, left hemiparesis, and ataxia. We highlight the importance of a detailed and selective study of AVM angioarchitecture with new sequences as XperCT (Philips Medical) viewing which permits a better understanding of the anatomy and pathology and a better therapeutical planning. Selective embolization of arterial feeders with Glubran2 (GEM) allows a better control of selected sectors of the AVM which may be difficult to access at surgery. This type of planning is especially important when the AVM is in close relationship with an important sulcus, as was the case of this patient whose AVM was adherent to the postcentral sulcus. We present the surgical nuances concerning patient positioning, craniotomy, AVM dissection, and resection. Early identification and interruption of the main arterial feeders facilitate further dissection. We discuss the timing of deep venous drainage interruption in AVMs with mixed superficial and deep venous drainage. The postoperative course was favorable and the postoperative angiogram showed complete resection of the AVM. At the last follow-up, the patient had only slight left ataxia. Multimodal management with planned selective embolization may facilitate microsurgical resection of AVMs. Given the retrospective nature of this report, informed consent was not required.