title: Surgery for a giant arteriovenous malformation without motor deterioration: preoperative transcranial magnetic stimulation in a non-cooperative patient.
abstract: 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.
authors.affiliation: Departments of Neurosurgery and.
authors.forename: Annick
authors.initials: A
authors.lastname: Kronenburg
authors.forename: Tristan
authors.initials: T
authors.lastname: van Doormaal
authors.forename: Pieter
authors.initials: P
authors.lastname: van Eijsden
authors.forename: Albert
authors.initials: A
authors.lastname: van der Zwan
authors.forename: Frans
authors.initials: F
authors.lastname: Leijten
authors.forename: Kuo Sen
authors.initials: KS
authors.lastname: Han
mesh_terms: D000293:Adolescent; D002543:Cerebral Hemorrhage / Q000150:complications / Q000209:etiology; D002648:Child; D006429:Hemiplegia / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery*; D002538:Intracranial Arteriovenous Malformations / Q000503:physiopathology* / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods; D010291:Paresis / Q000175:diagnosis / Q000209:etiology; D057234:Preoperative Period; D012008:Recurrence; D012720:Severity of Illness Index; D020521:Stroke / Q000150:complications / Q000209:etiology; D050781:Transcranial Magnetic Stimulation; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods; D017287:Ventriculoperitoneal Shunt
keywords: AChA = anterior choroidal artery; AVM = arteriovenous malformation; EVD = external ventricular drain; 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; arteriovenous malformation; brain mapping; eloquent area; fMRI = functional MRI; microsurgical resection; outcome; pediatric hemorrhagic stroke; vascular disorders