Contralateral Transfalcine Approach to Deep Parasagittal Arteriovenous Malformations-Technical Note

BACKGROUND: Resection of deep medial frontal and parietal arteriovenous malformations (AVMs) is often challenging due to a tangential angle of attack and deep, 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 neurologic 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 the unaffected hemisphere positioned in a gravitydependent manner in 5 cases. Surgical procedures were video documented, and an illustrative case is presented. All 5 patients had a modified Rankin Scale score of 0 or 1 at the last follow-up. RESULTS: Complete resection of the AVM was achieved in all 5 cases. No permanent major neurologic 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: The contralateral transfalcine approach is a useful technique in the 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 neurologic deficits.