Microsurgical Management Research Articles

Proximal Middle Cerebral Artery Aneurysms: Microsurgical Management and Therapeutic Results

Management of proximal (M1) middle cerebral artery (MCA) aneurysms can be challenging. Because of the diversity of aneurysm morphology and location of M1 aneurysms, the surgical strategy should be tailored to each individual case, especially for complex cases. We assessed the safety and efficacy of an algorithmic strategy for the management of M1 aneurysms. A prospective single-center study of M1 aneurysms treated with microsurgery was performed. Our algorithmic strategy was determined by the location and complexity (e.g., size, shape) of the aneurysms. The surgical modalities included neck clipping, aneurysm resection and/or trapping, and proximal occlusion with revascularization. The clinical and radiographic data were analyzed. From January 2007 to March 2017, 92 proximal MCA aneurysms in 92 patients were treated microsurgically. Aneurysm treatment techniques included clipping in 55, proximal occlusion in 21, aneurysm resection in 11, and trapping in 4. Bypass techniques included 2 anterior temporal artery reconstructions, 5 middle cerebral bifurcation reconstructions, 4 parent artery reanastomoses, 2 interpositional bypasses, 25 high-flow bypasses, and 7 medium-flow bypasses. Overall, good outcomes (modified Rankin scale score, 0-2) were seen in 49 of 92 patients (53.3%) at discharge and in 79 of 91 (86.8%) at the last follow-up visit. On the latest angiogram, 78 of 90 aneurysms (86.7%) had been completely occluded without a remnant. Bypass patency was confirmed in 38 of 43 bypass procedures. Our present treating strategy might provide a benefit for patients with proximal MCA aneurysms.

Microsurgical Management of a Previously Coiled Giant Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Microsurgical Management of a Previously Coiled Giant Middle Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Retrosigmoid Transmeatal Endoscope-Assisted Approach in Semi-Sitting Position for Resection of Vestibular Schwannoma: 2-D operative Video.

We present a case of a mid-sized vestibular schwannoma (T3b according to the Hannover classification) that was resected through a retrosigmoid transmeatal approach in semi-sitting position under endoscopic assistance. The patient is a 52-year-old male with acute loss of functional hearing on the right side. Audiometry confirmed a loss of up to 60 dB and lost speech discrimination, there were no associated symptoms such as tinnitus or vertigo. This 2D video demonstrates positioning, OR set-up, anatomical and surgical nuances of the skull base approach and the operative technique for microdissection of the tumor from the critical neurovascular structures, especially the facial and cochlear nerves. A gross total resection was achieved and the patient discharged home after four days with unaltered function of the facial nerve (HB I). At one year follow up there was no indication of residual or recurrence.In summary, the retrosigmoid transmeatal approach is an important and powerful tool in the armamentarium for the microsurgical management of all kinds of vestibular schwannomas. Provided the necessary anesthesiological precautions and intraoperative procedures the semi-sitting position is safe and effective. If needed, the approach can be complemented by the use of an endoscope for visualization of the distal internal auditory canal. The link to the video can be found at: https://youtu.be/pPKT4_5nIn0 .

Resection of a Petroclival Meningioma via the Endoscope-Assisted Retrosigmoid Approach: 2-D Operative Video.

We present a case of a petroclival meningioma that was resected through an endoscope-assisted retrosigmoid approach via corridors above and below the facial-vestibulocochlear nerve complex. The patient is a 61-year-old female with complaints of left-sided hypesthesia and neuralgia of the infraorbital and zygomatic region, intermittent periorbital myokymia, and a slight facial palsy (HB II). This 2D video demonstrates the operative technique, anatomical and surgical nuances of the skull base approach and microdissection of the tumor from the critical neurovascular structures. A gross total resection was achieved. The patient’s facial and trigeminal symptoms resolved completely within a few weeks. At 2 year follow up there was no indication of residual or recurrence.In summary, the retrosigmoid approach with endoscopic assistance is an important and powerful tool in the armamentarium for the microsurgical management of meningiomas of the lateroventral skullbase of the posterior fossa. The link to the video can be found at: https://youtu.be/Px4XIRDoALc .

Clinical progress of microsurgical management for lymphedema

To review the clinical progress of microsurgical management for lymphedema. The literature on microsurgical treatment for lymphedema at home and abroad in recent years was reviewed and analyzed. At present, conservative treatment is the main treatment for lymphedema, which has limited effectiveness only for early stages of lymphedema; and it is not curative and demands patient compliance. In contrast, microsurgical approaches can solve the problems in the prevention or management of lymphedema and showed promising results, such as lymphatic-venous anastomosis (LVA), vascularized lymph node transfer (VLNT), and other lymphatic reconstructions. Microsurgical approaches like LVA and VLNT have been broadly used in recent years, the effectiveness and safety have been proved. But the evidence of long-term randomized controlled studies is still required to establish standard treatment practices.

Combined Endovascular and Microsurgical Management of an Unruptured Grade 2 Parietal Arteriovenous Malformation: 2-Dimensional Operative Video.

Combined Endovascular and Microsurgical Management of an Unruptured Grade 2 Parietal Arteriovenous Malformation: 2-Dimensional Operative Video.

Combined Extradural and Intradural Pterional Transzygomatic Approach to Large Sphenoid Wing Meningiomas. Operative Technique and Surgical Results.

Objectives Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors. Design A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing. Results All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy. Conclusion Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence.

Microsurgical Management of Vascular Malformations of the Pineal Region

Vascular pineal malformations are rare and technically demanding lesions. Because the locations of these lesions, endovascular techniques and radiosurgery have been increasingly used in the recent decades to accomplish safe occlusion. Nevertheless, microsurgical treatment may be required sometimes. We present a retrospective review of the vascular pineal malformations operated by the senior author. Moreover, we report illustrative cases for the various types of vascular lesions with a careful analysis of the different microsurgical stages. Eighteen patients with pineal vascular lesions were operated on between 1980 and 2015: 6 patients had vein of Galen malformations, 5 plexiform arteriovenous malformations, 6 cavernous malformations, and 1 patient had a ruptured medial posterior choroidal artery aneurysm. A complete resection and occlusion was possible in all vascular malformations. The pineal region is an infrequent but challenging location for vascular lesions. A careful and stepwise operative strategy for the different types of vascular lesion is paramount to accomplish an effective and safe microsurgical treatment when other alternatives fail or are not available.

Microsurgical treatment of unruptured middle cerebral artery aneurysms: a large, contemporary experience.

Advances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery. The authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2-4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation. The authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4. In high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.

Dural Arteriovenous Fistulas of the Craniocervical Junction: Anatomical Considerations, Clinical Presentation, and Microsurgical Management

Dural Arteriovenous Fistulas of the Craniocervical Junction: Anatomical Considerations, Clinical Presentation, and Microsurgical Management

The Application of Sigmoid Sinus Tunnel-packing or Push-packing of the Inferior Petrous Sinus in the Microsurgical Management of Jugular Paragangliomas.

To analyze the outcomes of microsurgically treated jugular paragangliomas with control of bleeding from the inferior petrous sinus. Retrospective patient review. A single university hospital. Forty-three patients with jugular paragangliomas were diagnosed in the past 7 years in our clinic. Surgical tumor control, intraoperative blood loss, intraoperative management of the facial nerve, and the preoperative and postoperative function of the lower central nerves. Twenty-six patients underwent microsurgical treatment. Eighteen tumors were class C2 (69.2%), six were class C3 (23.1%), and two were class CDe1 (7.7%). Gross total tumor resection was achieved in 92.3% of the patients. The mean blood loss during surgery was 438.5 ml. The recurrence rate was 3.8% over a mean follow-up of 29.2 months. New facial palsy and lower cranial nerve deficit occurred in 42.3 and 11.5% of the patients, respectively. The infratemporal fossa approach type A with sigmoid sinus tunnel-packing or push-packing technique facilitated the control of bleeding from the inferior petrous sinus and improved the outcomes of microsurgical treatment for jugular paragangliomas.

Augmentation surgery on the cartilaginous portion of the vocal fold in a patient with cricoarytenoid joint ankylosis

Surgical management of cricoarytenoid joint (CAJ) ankylosis is challenging and has the risk of worsening voice quality. In the present case, augmentation surgery was performed on the cartilaginous portion of the vocal fold in a patient with CAJ ankylosis. A 24-year-old man sustained blunt trauma to the anterior neck three years prior to developing severe breathiness. Posterior glottal insufficiency resulting from lateral fixation of the right vocal fold was observed during phonation under laryngoscopy. In addition, electromyography and CT scan revealed severe ankylosis of the right CAJ. Type I thyroplasty performed on the right vocal fold did not improve postoperative vocal function. Therefore, augmentation surgery on the cartilaginous portion of the right vocal fold was performed via endolaryngeal microsurgery under general anesthesia with jet ventilation. A piece of temporalis fascia was autotransplanted into the submucosal space created at the posterior cartilaginous portion of the right vocal fold. This resulted in the narrowing of the posterior glottal gap during phonation, leading to improvement in hoarseness. Microsurgical management with autologous fascia augmentation of the cartilaginous portion of the vocal fold can be effective in patients with lateral vocal fold fixation due to CAJ ankylosis.

One burr-hole craniotomy: Suboccipital midline approach to the fourth ventricle in Helsinki neurosurgery.

Background:In this video-abstract, we present one burr-hole craniotomy for the standard suboccipital midline approach developed in Helsinki neurosurgery for the microsurgical management of forth ventricle lesions, distal posterior inferior cerebellar artery aneurysms, and tumoral and vascular lesions of the vermis, cisterna magna region, and posterior brainstem as well.Case Description:We prefer to position the patient in sitting praying position. A midline straight single-layer incision starts on the inion and extends caudally toward the level of C2. The muscles are divided with diathermia along the occipital bone. Three curved retractors, two upward and one downward, provide a wide clean space for the craniotomy. Finger palpation and blunt dissection with cottonoids balls provide identification of the foramen magnum and the spinous process of C1. A burr-hole is made 1 cm lateral and below the level of the transverse sinus. After the detachment of the dura with a curved angled dissector, two cuts from both sites of the burr-hole are made with the craniotome. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (yasargil dissector) is used for the detachment of the bone from the dura. A craniotomy around the midline overlying the occipital sinus and the falx cerebelli is performed to expose medial aspects of cerebellar tonsils, the medulla oblongata, and the occipital sinus. Special care should be taken to avoid damaging the vertebral artery and the epidural sinuses running at the foramen magnum. A few drill holes are made for tack-up sutures. After a craniocervical-based opening of the dura, the fourth ventricle is accessed directly by telovelar route.Conclusion:The described one burr-hole craniotomy may represent the more efficient manner for performing the suboccipital midline approach to the fourth ventricle.Videolink:http://surgicalneurologyint.com/videogallery/suboccipital-midline-approach/

One burr-hole craniotomy: Supracerebellar infratentorial paramedian approach in Helsinki Neurosurgery.

Background:In this video abstract, we present a one burr-hole craniotomy for the standard supracerebellar infratentorial (SCIT) paramedian approach developed in Helsinki Neurosurgery for the microsurgical management of pineal region lesions, tentorial meningiomas, as well as arteriovenous malformations, aneurysms, and intrinsic tumors of the superior surface of the cerebellum. In this regard, the use of praying sitting position in Helsinki Neurosurgery, which is a more ergonomic variant of the classic sitting position, offers several advantages such as lower intracranial pressure, good venous outflow, gravitational retraction, and straight anatomical orientation.Case Description:The patient is placed in sitting praying position. A straight single-layer incision is made 2–3 cm lateral from the midline, starting about 1 inch cranial from the inion and extending caudally toward the foramen magnum. Curved retractors provide a wide clean space for craniotomy. A burr-hole is made above the transverse sinus, which may be identified by its anatomic relation with superior muscle insertion line on the occipital bone. After detachment of the dura with blunt dissectors, a craniotomy around the transverse sinus and continuing to the confluens sinuum is performed to expose about 3 cm of the dura below the level of the transverse sinus. In case of an adherent dura particularly present in elderly patients, a long blunt flexible dissector (Yasargil dissector) is used for the detachment of the bone from the dura. A few drill holes are made for tack-up sutures. Finally, a hemostatic agent covers the transverse sinus and a sinus-based dura opening is performed under the microscope.Conclusion:One burr-hole craniotomy for an SCIT paramedian approach may represent the more efficient procedure for approaching the pineal region, inferior surface of the tentorium, and the superior surface of the cerebellum as well.Videolink:http://surgicalneurologyint.com/videogallery/paramedian-subocciptal-approach

Clinicopathological Features and Microsurgical Management of Lesions Located in the Cavernous Sinus: Analysis of 66 Cases.

To investigate the clinicopathological features and related factors affecting microsurgical resection of lesions in the cavernous sinus. Clinical data of 66 patients undergoing microsurgery for lesions located in the cavernous sinus from January 2011 to December 2017 were retrospectively reviewed. Histopathological examination revealed benign lesions in 60 (90.9%) patients, the most common histopathological types were meningiomas, schwannomas, and cavernous hemangiomas. Only six (9.1%) patients had malignant lesions. The gross total resection rate was 33%, subtotal resection rate was 21%, substantial partial resection rate was 26%, and partial resection rate was 20%. Factors influencing the extent of lesion resection included the presence of cavernous sinus syndrome prior to surgery, the size of the lesion, the site of origin, and the surrounding of the internal carotid artery, all of which detrimentally influenced total excision (p < 0.05). Most lesions involving the cavernous sinus are histopathologically benign. Preoperative cavernous sinus syndrome, the size of the lesion, the site of origin, and the surrounding of the internal carotid artery all detrimentally influence the extent of lesion resection.

Microsurgical management results of occipital encephalocele

Background Encephalocele is a central nervous system birth anomaly with a herniation of the brain and the covering meninges through a bony skull defect to the exterior.Objective The aim of this research was to describe the prognostic factors and current possible hypotheses explaining associated anomalies observed in a series of 17 patients with encephalocele and show the effectiveness of setting up a microsurgical technique in the treatment of these cases.Materials and methods Seventeen patients who were identified with occipital encephaloceles and referred to our Neurosurgery Clinic at the Mansoura University Hospital, Mansoura Insurance Hospital, between October 2004 and July 2013 were enrolled in this study. Patients’ sex, age at the time of the procedure, features of the lesion including site, size, associated cerebrospinal fluid leak, radiological evaluation and intraoperative findings (sac contents), and intracranial and extra cranial-associated anomalies were determined in the study.Results In our study, 17 patients (12 female and five male) were included. Their ages varied between newborn and 1 month. The encephalocele sac was situated in the occipital region in 15 (88.2%) patients and in the occipitocervical region in two (11.8%) patients. We used a microsurgical technique on all patients. Five (29.4%) of the 17 patients died: three in the postoperative early period (0–7 days) and two in the late postoperative period (2 weeks to 3 months). The mortality rate in our study was 29.4%.Conclusion The evidence in our series showed the importance of some factors that can alter the survival of patients with occipital encephalocele such as the sac size, the neural tissue existence in the content, hydrocephalus, infections, and other associated malformations. In this study, we report improvements in the surgical results by introducing the microsurgical technique as an alternative to traditional management despite the high morbidity and mortality linked to this congenital anomaly.

Unedited microneurosurgery of a high-grade pineal parenchymal tumor of intermediate differentiation.

Background:WHO Grade II–III pineal parenchymal tumors of intermediate differentiation (PPTIDs) were included in the 2007 World Health Organization Classification of Central Nervous System Tumors as pineal parenchymal tumors between pineocytomas and pineoblastomas. PPTIDs comprise more than 20–60% of all pineal parenchymal tumors (PPT) s and are characterized by moderately high cellularity, mild-to-moderate nuclear atypia, and low-to-moderate mitotic activity. Moreover, PPTID includes transitional cases in which pineocytomatous and pineoblastoma features are associated. Synaptophysin and neuron-specific enolase are usually positive, with variable reactivity to neurofilament protein, chromogranin A, retinal S-antigen, and S-100 protein. PPTID Grades II and III can be distinguished on the basis of mitotic activity (higher in high-grade PPTID) and neurofilament protein immunoreactivity (higher in low-grade PPTID). Herein, we present the microsurgical management of a histologically confirmed high-grade PPTID.Case Description:A patient with high grade PPTID underwent sitting praying position and right paramedian supracerebellar infratentorial approach. The lesion was identified after lateral opening of the quadrigeminal cistern, followed by removal of its cystic component. Tissue samples were obtained under high microscopic magnification, and internal debulking of the tumor was performed with ring microforceps and bipolar forceps in the right hand and a thumb-regulated suction tube in the left hand. Continuous water irrigation provided us a clean surgical field and the recognition of small bleeding vessels. Moreover, water dissection technique was applied to recognize the cleavage plane of the tumor. Bipolar coagulation forceps were used to shrink the tumor and remove it by piecemeal reduction aiming to identify the anterior and lateral limits of the lesion. The poorly differentiated borders between the tumor and the surrounding parenchyma were determined under microscopic vision. Small vessels feeding the tumor were coagulated and cut. The most critical surgical stage was related with removal of some tumor remnants attached to the internal cerebral veins. A meticulous and skillful dissection was essential aiming to preserve these vascular structures. The final steps included meticulous hemostasis with electrocoagulation, Tachosil, and Surgicel. The postoperative course was uneventful. The patient underwent adjuvant radiotherapy and currently is alive, free of tumor recurrence 4 years after surgery.Conclusion:This unedited video offers all detailed aspects that are, as the senior author JH considers, essential for a neurosurgeon when performing an efficient and safe surgery for a high-grade PPTID.Videolink:http://surgicalneurologyint.com/videogallery/pineal-tumor-2

Microsurgical Management of Tuberculum Sellae Meningiomas by the supraorbital keyhole eyebrow approach: Surgical Outcome

The aim of this study was to evaluate (surgical) visual outcomes in patients treated via supraorbital keyhole eyebrow incision approach. Data from 14 patients with TSMs (Tuberculum Sellae Meningioma) who underwent microsurgical treatment by a supraorbital keyhole eyebrow skin incision between September 2006 and September 2013 were retrospectively collected and analyzed. Patients were analyzed on the basis of clinical, radiological, and surgical factors that appeared to affect the outcome. To quantify the extent of ophthalmological disturbances Visual impairment score was used to analyze visual acuity and visual fields, which range from 0 (best) to 100 (worst). Change in visual function was assessed as the main outcome. The mean age of the 10 women and 4 men enrolled in the study was 56.50years (range, 42~74 years). The presenting symptom was asymmetrical visual loss in 71.4% of the patients.And examination revealed decreased visual acuity (Snellen notation) in 100% and impaired visual fields (Goldmann perimetry) in 58.3 % (7/12 cases, central scotoma and temporal anopia n=1, classical bitemporal hemianopia n=4, incongruent homonymous hemianopia n=2 , 2 cases data N/A) of the patients. Simpson grades I resection via a supraorbital keyhole eyebrow skin incision approach, were achieved in 100% of the patients. Quality of life was assessed according to Karnofsky scale and was 86.67 (range: 70~100). The mean follow-up duration was 51.73 months (range: 27~91 months).No recurrent tumors were observed during this period. According to the findings of this study, this approach provides a pleasing cosmetic outcome and also decreases brain manipulation while minimizing the likelihood of procedure-related morbidity. A favorable visual outcome was observed in most of the patients in the late postoperative period. Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, page : 26-32

Microsurgical management of benign lesions interior to the cavernous sinus: A case series.

Background:Benign lesion interior to the cavernous sinus (CS) is very rare.Objective:In this series we found nonneoplastic lymphatic aggregation and osteoclastoma inside the CS which is very rare and probably not reported in literature. One interesting postoperative complaint of feeling of tickling down of warm water under the skin forehead was found in the patient of inflammatory disease of CS which is not reported in literature. Here we also describe our experiences of microsurgical management of series of benign lesions inside the CS.Materials and Methods:Benign mass originated from the content of CS or inner side of walls of CS, confirmed peroperatively were included in this series. Prospectively recorded data of microsurgical management was retrogradely studied.Results:Total number of patient was 12. Patient's age range was 30–60 years. Follow-up range was 60 months to 19 months. Three was nonneoplastic lesion (tuberculosis, inflammatory and nonneoplastic lymphoid infiltration). Among the 9 neoplastic lesions, two hemangiomas, two meningiomas, three 6th nerve schwannomas, one osteoclastoma and one epidermoid tumor. Middle cranial fossa-subtemporal extradural approach was used in 9 cases and in two cases extended middle fossa zygomatic approach. New postoperative 3rd nerve palsy developed in 5 cases all recovered completely except one. In seven patients 6th nerve palsy developed after operation; only one recovered. Postoperatively simultaneous 3rd, 4th and 6th nerve palsy developed in four cases. One interesting postoperative complaint of feeling of tickling down of warm water under the skin of left sided forehead was found in the patient of inflammatory disease of CS. Mortality was nil. Total resection was done in 9 cases. There was no recurrence till last follow-up.Conclusion:Though decision for microsurgical removal of such lesions is not straight forward. Probably microsurgery is the best option in treating such benign lesions though it may associate with some permanent cranial nerve palsy.

Microsurgical management of a high-grade brain arteriovenous malformation in the central lobe after unsuccessful radiosurgery

The recommendation for the great majority of high-grade brain arteriovenous malformations (bAVMs) is observation, except for those patients with recurrent hemorrhages, progressive neurological deficits, steal-related symptoms, or AVM-related aneurysms, for whom intervention should be considered. These are general recommendations, and the decision should be made on an individual basis. Surgical resection of an AVM in the central lobe may cause postoperative sensorimotor deficits since this anatomical region includes the pre- and postcentral gyri on the lateral surface and the paracentral lobule on the medial surface. The authors present a patient with a ruptured high-grade bAVM in the central lobe who underwent previous surgery for hematoma evacuation and previous radiosurgery, and whose indication for reoperation was proposed based on progressive hemiparesis. Microsurgical resection was possible after a wide frontoparietal craniotomy, which made all the nidus borders accessible. This case illustrates the anatomy and surgical technique for large nidus AVMs in eloquent areas, showing that complete microsurgical resection is possible with good clinical outcome. The video can be found here: https://youtu.be/Cpd1PK6BLIM .