Contralateral transfalcine approach to deep parasagittal AVMs – technical note

Abstract: Background Resection of deep medial frontal and parietal arterio-venous malformations (AVM) is often challenging due to a tangential angle of attack, deep and narrow working corridor. Adequate visualization of the AVM and its feeding arteries without brain retraction is of particular importance when operating in or near eloquent cortical areas, where brain manipulation could inadvertently result in neurological deficits. The aim of this paper is to provide a step by step description of surgical approach and report our experience with the contralateral transfalcine approach for resection of deep seated parasagittal AVMs. Methods Contralateral transfalcine resection of deep frontal, parietal and cingulate gyrus AVMs was performed with unaffected hemisphere positioned in a gravity dependent manner in five cases. Surgical procedures were video documented and an illustrative case is presented. All 5 patients had modified Rankin Score of 0 or 1 at the last follow-up. Results Complete resection of the AVM was achieved in all five cases. No permanent major neurological deficit was observed postoperatively. This approach allowed a superior visualization of arterial feeders, the parenchymal side of the AVM and an early control of small parenchymal feeders, while minimizing retraction of the brain. Conclusions Contralateral transfalcine approach is a useful technique in cerebrovascular surgeon’s armamentarium for management of deep seated medial frontal, parietal and cingulate gyrus AVMs in or around eloquent brain areas, allowing to minimize normal brain retraction and avoid associated neurological deficits.