Surgery for a giant arteriovenous malformation without motor deterioration: preoperative transcranial magnetic stimulation in a non-cooperative patient

Case report

Annick Kronenburg M.D.1, Tristan van Doormaal M.D., Ph.D.1, Pieter van Eijsden M.D., Ph.D.1, Albert van der Zwan M.D., Ph.D.1, Frans Leijten M.D., Ph.D.2, and Kuo Sen Han M.D., Ph.D.1
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  • 1 Departments of Neurosurgery and
  • | 2 Clinical Neurophysiology, Brain Center Rudolf Magnus, UMC Utrecht, The Netherlands
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Transcranial magnetic stimulation (TMS) is a noninvasive activation method that is increasingly used for motor mapping. Preoperative functional mapping in vascular surgery is not routinely performed; however, in cases of high-grade arteriovenous malformations (AVMs), it could play a role in preoperative decision making. A 16-year-old male was suffering from a giant, right-sided insular, Spetzler-Martin Grade V AVM. This patient's history included 3 hemorrhagic strokes in the past 3 years, resulting in Medical Research Council Grade 2–3 (proximal) and 2–4 (distal) paresis of the left side of the body and hydrocephalus requiring a ventriculoperitoneal shunt. Preoperative TMS showed absent contralateral innervation of the remaining left-sided motor functions. Subsequently, the AVM was completely resected without any postoperative increase of the left-sided paresis. This case shows that TMS can support decision making in AVM treatment by mapping motor functions.

Abbreviations used in this paper:

AChA = anterior choroidal artery; AVM = arteriovenous malformation; EVD = external ventricular drain; fMRI = functional MRI; GCS = Glasgow Coma Scale; HS = hemorrhagic stroke; ICA = internal carotid artery; MCA = middle cerebral artery; MEG = magnetoencephalography; MRA = MR angiography; MRC = Medical Research Council; PCA = posterior cerebral artery; TMS = transcranial magnetic stimulation; VP = ventriculoperitoneal.

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