Challenges of Complex AVM Resection in Regional and Community Hospitals: A Case Report

We report the microsurgical management of a complex diffuse arteriovenous malformation (AVM) in a regional hospital. A 46-year-old woman with hypertension and chronic kidney disease presented with a five-day history of mood changes, emotional lability, speech difficulties, and gait instability. Imaging revealed a 4-cm left frontal intraparenchymal hemorrhage and a diffuse AVM with dual venous drainage (Supplemented Spetzler-Martin grade 6). She underwent resection via an anterior interhemispheric approach, including early hematoma evacuation, careful identification and sequential coagulation of arterial feeders, and circumferential dissection while preserving functional brain tissue. Intraoperative indocyanine green videoangiography confirmed complete resection. Postoperatively, she developed a generalized tonic-clonic seizure and transient expressive aphasia with right-sided weakness, which resolved with prompt seizure management and strict blood pressure control. Follow-up angiography at four weeks confirmed no residual AVM. This case demonstrates that even high-grade diffuse AVMs can be safely resected in community hospitals when meticulous microsurgical technique is combined with structured perioperative management, close multidisciplinary coordination, focused neurocritical care training, and institutional preparedness. These strategies are critical to achieving safe outcomes outside tertiary centers.

Arteriovenous malformation Community Hospital Neurocritical care Microsurgery Diffuse AVM