Surgical management of a lenticulostriate artery aneurysm and an associated initially less-appreciated arteriovenous malformation: two-dimensional video.

Surgical management of the basal ganglia vascular lesions needs a personalized surgical strategy due to intricate neurovascular anatomy and eloquent surrounding structures. This report describes the successful resection of a perforator aneurysm and an initially less-appreciated arteriovenous malformation (AVM) at the basal ganglia in a 15-year-old male. Preoperative digital subtraction angiography (DSA) and high-resolution magnetic resonance imaging (MRI) showed a deep-seated basal ganglia aneurysm on a lenticulostriate artery (LSA) perforator with a distal suspicious early drainage vein adjacent to a hematoma. After a thorough discussion, a trans-Sylvian/trans-insular microsurgical obliteration of the aneurysm and exploration of the suspected micro-AVM utilizing the hybrid operating room was planned for this patient, and informed consent was obtained [1-5]. After craniotomy, the Sylvian fissure was sharply dissected to expose the insular lobe. Subsequently, the hematoma cavity was opened to expose and clip the aneurysm under the guidance of the neuronavigation system and intraoperative neurophysiological monitoring (IONM). After isolating the aneurysm, the micro-AVM distal to the aneurysm was clearly revealed in the intraoperative DSA review. With stable IONM over a 30-minute clip occlusion of the aneurysm and the parent artery, both the AVM and the aneurysm were resected. Repeat intraoperative DSA confirmed complete obliteration of both lesions, and no IONM changes (motor/somatosensory evoked potentials) occurred. Postoperative monitoring addressed hemorrhage, vasospasm, and neurological deficits. At 6-month follow-up, DSA and MRI showed sustained obliteration and sequela-free recovery. We hope that this case can underscore the surgical nuances and tricks in rare LSA lesions within the basal ganglia.