Awake Craniotomy for a Ruptured Arteriovenous Malformation With Preoperative Navigated Transcranial Magnetic Stimulation for Language Mapping: 2-Dimensional Operative Video

Preoperative navigated transcranial magnetic stimulation (nTMS) was used to noninvasively map eloquent speech areas in a 53-year-old right hand dominant woman with a ruptured Spetzler Martin Grade II arteriovenous mal-formation (AVM) in the left supramarginal gyrus who presented with speech arrest. This functional map correlated closely with awake intraoperative direct cortical stimulation. Preoperative functional MRI and MRI with tractography were also performed. The presence of perilesional blood products and high vascular flow as seen in this AVM are known to cause image degradation and false activation in functional MRI BOLD sequences because of field in-homogeneity and neurovascular uncoupling, respectively. nTMS avoids these pitfalls to generate high-fidelity, submillimeter noninvasive functional maps on which diffusion tensor imaging tractography may be superimposed. An awake craniotomy was performed 2 months after initial rupture; the participants and any identifiable individuals consented to publication of his/her image, and the patient consented to the procedure. Preoperative neuro-psychological evaluation indicated that the patient's speech had almost completely recovered by this time. Motor, sensory, and language mapping were performed intraoperatively. During resection, the patient experienced transient speech deficits which resolved after modification of the surgical avenue. Subcortical mapping was negative, and the nidus was completely removed; this was confirmed on postoperative diagnostic cerebral angiogram. Postoperative imaging was negative for ischemic injury or hemorrhage. The patient experienced significant dysphasia in the immediate postoperative period which improved by postoperative day 3, with near total resolution by postoperative day 14. nTMS may be a useful modality for noninvasive preoperative functional mapping of speech inpatients with AVMs