Awake Resection of an Arteriovenous Malformation

Arteriovenous malformations (AVMs) are a highly complex array of abnormal arteries and veins that directly fistulize without intervening capillary beds.¹ As AVMs can differ in size, location, and morphology, specific clinical management is determined for each individual patient, in conjunction with their specific goals and needs.² This Video demonstrates the resection of an AVM located in the language area of eloquent cortex of a 38-year-old opera singer. The patient presented to the emergency department with a new-onset seizure. Magnetic resonance imaging including task-based functional imaging demonstrated a left post temporal AVM with associated hemosiderin-stained white matter and language activation just posterior to the lesion. Awake microsurgical resection was recommended given her career as an opera singer and the high-risk location of the AVM in proximity to eloquent language cortex, with additional goals of preventing further risk of hemorrhage and reduction in the risk of epilepsy. The patient underwent a left temporoparietal craniotomy with direct electrical stimulation-based language mapping and monitoring along with microsurgical resection of the AVM with image guidance, confirmed with intraoperative indocyanine green angiography. Postoperative angiography demonstrated no residual AVM with preservation of normal arterial and venous anatomy. At follow-up, the patient was clinically intact, seizure free, and off all antiepileptic medications. At 3 months, she resumed her career as an opera singer. Awake resection with intraoperative functional mapping can be used for select small AVMs to avoid injury to functional tissue and allow more aggressive resection of potentially epileptogenic tissue.