In a previous review of 132 patients with parafalcine and midline arteriovenous malformations (AVMs), we exposed all AVMs with a bilateral craniotomy across the superior sagittal sinus (SSS) and a wide opening of the interhemispheric fissure to access deep feeders from the anterior and posterior cerebral arteries, as well as important draining veins on the medial hemisphere.1 The bilateral craniotomy completely exposed the midline to optimize access and visualization. In all of these operations, the AVM was approached ipsilaterally in order to keep the anatomy completely in view and have full access to the nidus. With many medial frontal AVMs, an ipsilateral anterior interhemispheric approach (IAIA) was used with the midline positioned horizontally to allow gravity to retract the frontal lobe ipsilateral to the AVM, creating a deep and perpendicular perspective with limited access to the margins of the AVM other than that on the medial surface. The AVM was dissected up from the sagging frontal lobe, drawing the AVM medially into the interhemispheric fissure with restricted access to the lateral and deep margins that often receive supply from challenging lenticulostriate or insular perforating arteries travelling through deep frontal white matter.
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