Surgical resection of Wernicke’s area brain arteriovenous malformation via posterior Sylvian fissure: Two-dimensional video

Abstract

The brain arteriovenous malformation (BAVM) within language-eloquent area poses a significant surgical challenge, demanding meticulous planning to ensure both preservation of language function and curative resection. This report details the successful microsurgical resection of a Spetzler-Martin grade II BAVM located in Wernicke’s area in a 51-year-old male, ruptured three weeks ago and characterized by mild anomia. Following thorough discussion, the patient elected for microsurgery, providing informed consent, and the procedure was approved by the ethics committee. Given concerns regarding patient compliance during a prolonged procedure, the intravenous general anesthesia was favored over an awake craniotomy approach. Diffusion tensor imaging showed language-related neurofibers around the lesion. Functional magnetic resonance imaging was not employed due to potential inaccuracies arising from neurovascular uncoupling caused by BAVM hemodynamics[1]. Instead, intraoperative spatial–temporal functional mapping with cortico-cortical evoked potentials was implemented to delineate the language area, approximating the benefits of awake mapping[2,3]. After craniotomy, intraoperative inspection and spatial–temporal functional mapping elucidated the anatomical relationship between the BAVM and the language-eloquent cortex. The posterior Sylvian fissure was then sharply dissected to access the hematoma cavity and BAVM nidus, and the nidus was subsequently dissected and resected along its boundary with minimal disruption to the surrounding parenchyma. Intraoperative indocyanine green videoangiography and digital subtraction angiography confirmed restoration of normal hemodynamics and complete BAVM obliteration. Postoperatively, the patient exhibited no language function deterioration and demonstrated sustained symptomatic improvement at one-month follow-up. This case serves to highlight technical nuances relevant to the management of BAVMs within critical language areas.