Craniotomy and direct access microcatheterization for preoperative embolization of a complex, high grade intracranial arteriovenous malformation.

The optimal management of complex, Spetzler-Martin Grade 5 arteriovenous malformations (AVMs) remains a challenge, despite the availability of endovascular, surgical and radiosurgical treatment options. In cases requiring treatment due to progressive neurological deficit or recurrent hemorrhage, preoperative embolization may be an extremely useful adjunct to definitive surgical resection, and is usually accomplished via the transarterial route using liquid embolysate. However, this treatment approach often mandates access to distal arterial pedicles that can be technically challenging by standard endovascular approaches. This video describes a left parietal craniotomy for direct access microcatheterization and embolization of an otherwise endovascularly inaccessible Spetzler-Martin Grade 5 AVM prior to definitive surgical resection. The case was performed in the hybrid operative suite with biplane intraoperative angiography. Technical considerations, operative nuances and outcomes are reviewed.