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J Neurosurg Pediatr. 2014 Jul;14(1):38-42. doi: 10.3171/2014.4.PEDS13592. Epub 2014 May 9.

Surgery for a giant arteriovenous malformation without motor deterioration: preoperative transcranial magnetic stimulation in a non-cooperative patient.

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Departments of Neurosurgery and.


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.


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

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