Multimodal Approach for Treatment of Hemorrhaged Mesencephalic Arteriovenous Malformation

Brainstem arteriovenous malformations (AVMs) are complex and life-threatening lesions. In our video (Video 1), we illustrate resection of a posterior midbrain hemorrhaged AVM (Spetzler-Martin grade III, Lawton-Young grade III, Supplementary Spetzler-Martin grade 6) in a 55-year-old woman presenting with ventricular hemorrhage and coma. Multimodal therapy with endovascular embolization of an associated prenidal aneurysm of the right posteromedial choroidal artery, followed by microsurgical resection via supracerebellar-infratentorial approach, is demonstrated. A total resection of the AVM was achieved. At the 4-year follow-up, the patient had a modified Rankin Scale score of 3. AVMs in eloquent brain regions require a carefully tailored, multimodal diagnostic and therapeutic approach to limit procedure-related complications and obtain acceptable outcomes. Herein, we illustrate such a situation and discuss some key points for success.