Microsurgical resection and endovascular embolization of a left inferior frontal and Sylvian Spetzler-Martin grade 3 arteriovenous malformation.

BACKGROUND

Arteriovenous malformations (AVMs) carry an estimated 2-4% annual risk of rupture, with an estimated 70-75% lifetime risk. They are typically discovered during young adulthood, occurring in approximately 5/10,000 individuals. Modalities of treatment involve endovascular treatment, Gamma Knife, microsurgical resection under general anesthesia, awake craniotomy, or a combination of these modalities.

CASE DESCRIPTION

We present the case of a 33-year-old male presenting with headaches who was found to have an incidental left inferior frontal Spetzler-Martin Grade 3 AVM adjacent to Broca's area. Given the large size of the AVM, the patient's young age, and the lifetime risk of rupture, the patient underwent a planned 2-stage preoperative embolization and microsurgical resection under general anesthesia with intraoperative monitoring. Complete resection of the AVM was observed on postoperative digital subtraction angiography. The patient was discharged home on postoperative day 4. The patient's transient postoperative mixed aphasia had fully resolved by the time of discharge. A review of the benefits of preoperative embolization and the technical considerations of resection of a large AVM in eloquent regions of the brain are included. The patient consented to the procedure and the publication of his images. The Institutional Review Board approval was deemed unnecessary due to the retrospective, case-report nature of this work.

CONCLUSION

Large AVMs in the eloquent brain can present a challenge to the surgeon. Staged, multi-modality intervention involving staged preoperative embolization and functional MRI preoperative planning can be an effective treatment strategy for strategic, safe microsurgical resection under general anesthesia for AVMs in the eloquent brain.