Strategies for microsurgical resection of an arteriovenous malformation in the superior limiting sulcus of the insula: The importance of combined treatment and mastery of the sylvian fissure anatomy

The insular lobe is an infrequent location for arteriovenous malformations (AVM). They may be located in the limen, the long and short gyri, and the limiting sulci. Due to their location, feeders arise from the M2 and M3 segments of the middle cerebral artery (MCA), and they usually have superficial drainage, although deep drainage may also occur. Microsurgical resection requires a deep knowledge of the anatomy of the sylvian fissure and the opercula. It is particularly challenging due to the AVM's deep location and its proximity to the MCA and the primary motor area in the precentral gyrus of the frontal operculum.^1-8 We report the case of a 38-year-old female with proteins C and S deficiency, who presented with worsening chronic headache. MRI and subsequent angiography revealed an AVM located in the right limiting sulcus of the insula. We opted for combined treatment with preoperative embolization, aiming, among other factors, to reduce the pressure of the large drainage vein situated along the dissection path. This approach facilitated a safer nidus dissection. Microsurgical resection was performed via the ascending ramus of the sylvian fissure, achieving a safer resection of the AVM regarding the retraction of the frontal operculum. Postoperative MRI and angiography demonstrated a complete resection of the AVM without complications (see Video 1). The patient evolved without neurological complications and deficits. The patient consented to the procedure and to the publication of his/her image. This study was approved by the Ethics and Research Committee of our institution.