Sequential arterial feeder targeting with microscope-based augmented reality and multimodal navigation for brain arteriovenous malformation resection: an integrated operative workflow in 158 cases

OBJECTIVE Early proximal arterial control is an established principle of brain arteriovenous malformation (bAVM) microsurgery but remains difficult to execute when feeding arteries are deep, obscured, or not apparent at the cortical surface. Herein, the authors describe the longitudinal clinical implementation of a workflow using multimodal navigation and microscope-based augmented reality (AR) to identify and target arterial feeders before substantial nidal dissection in bAVM resections. METHODS Case-specific multimodal datasets were assembled according to clinical relevance and availability from CTA, high-resolution structural MRI with thin-slice T2-weighted imaging, MRA, and 3D rotational DSA studies and were fused within standard clinical neuronavigation platforms. All angiographically identifiable arterial feeders were segmented along their surgically relevant courses, prioritized as operative targets, and incorporated into exposure and corridor planning. Targets were displayed intraoperatively using the available navigation configuration, including microscope-based AR as the technology evolved. Functional MRI (fMRI) and diffusion tensor imaging (DTI) were coregistered selectively to provide cortical and tractographic context. Consecutive navigation-assisted bAVM resections performed by a single neurosurgeon from 2013 to 2025 were analyzed. Outcomes included angiographic obliteration, perioperative morbidity, mortality, and modified Rankin Scale (mRS) score change relative to baseline. RESULTS Of 192 bAVM resections performed during the study period, 158 consecutive navigation-assisted resections comprised the analytical cohort and included Spetzler-Martin (SM) grades I–V. Complete obliteration on initial angiography after microsurgery was observed in 97.5% of cases (154/158). At a median follow-up of 15 months, 93.0% of patients were functionally independent (mRS score 0–2). An increase in the mRS score relative to baseline occurred in 18.4% of patients, most commonly reflecting minor, nondisabling deficits with preserved independence. Loss of independence attributable to surgery occurred in 3.1% of patients, and the mortality rate was 1.3%. CONCLUSIONS Multimodal navigation with microscope-based AR was implemented longitudinally to identify and target arterial feeders before substantial nidal dissection, with selective integration of fMRI and DTI providing cortical and tractographic context for lesions near eloquent anatomy. Across SM grade I–V bAVMs, the workflow was feasible and was associated with high rates of angiographic obliteration and functional independence. By translating preoperative angioarchitecture into a planned sequence of discrete intraoperative arterial targets within their structural and functional context, the featured workflow provides a structured framework for operative planning, execution, and teaching in feeder-directed bAVM microsurgery.