Aberrant drainage of posterior condylar emissary vein and abnormal orifice of hypoglossal canal: surgical implications in the transcondylar fossa approach for VA-PICA junction aneurysm.

BACKGROUND: The posterior condylar emissary vein (PCEV) and posterior condylar canal (PCC) are anatomical landmarks for identifying important structures like jugular tubercle and occipital condyle in surgical approach to the foramen magnum and condylar fossa. Several anatomical variations have been described. Drainage into the jugular bulb is found to be commonest. METHOD: A 70-year-old patient with unruptured vertebral artery-posterior inferior cerebellar artery (PICA) junction aneurysm-underwent surgical clipping via transcondylar fossa approach. RESULT: Preoperative computed tomography demonstrated an abnormal communication existed between the left-sided PCC and hypoglossal canal (HC). The PCEV was identified draining into a dilated venous channel/pouch at the "hip" of sigmoid sinus (junction of sigmoid sinus and jugular bulb). Intra-operatively, an occipital artery-PICA bypass was performed. The PCEV was skeletonized, coagulated, and divided to achieve hemostasis. The lateral and cranial drilling around PCC was successful at safeguarding the underlying contents of HC (in medial and caudal extent). CONCLUSION: Preoperative angiography and detailed morphometric analysis of the PCC were helpful in planning surgical approach-identifying and controlling the PCEV, and skeletonization of the PCC without compromising the hypoglossal nerve and anterior condylar emissary vein.

Differences Between Subarachnoid Hemorrhage Seen in Daily Practice and Aneurysms That Rupture During Follow-Up.

[Figure: see text].

Outcome of retreatment for recurrent saccular cerebral aneurysms: a propensity score-matched analysis.

Although endovascular or surgical treatment has been performed for preventing the rupture of saccular cerebral aneurysms (sCA), in some patients, the aneurysms may recur and require retreatment. We aimed to investigate the clinical and radiological outcomes of treating recurrent sCA. We retrospectively evaluated the data of 52 patients with 60 recurrent sCAs who were retreated and 1534 patients with 1817 sCAs who received initial treatment. The primary outcome was a recurrence of the aneurysm. Secondary outcomes were an additional treatment, rupture after treatment, and a neurological worsening, which was defined as an increase of 1 or more scores using the modified Rankin Scale at 12-month. Safety outcomes included postoperative ischemic and hemorrhagic complications. We compiled the 120 (60 each) propensity score-matched cohort based on a propensity score for the treatment of recurrent sCA. In the propensity score-matched cohort, recurrence after treatment was observed in 25% and 6.7% of cases in the retreatment and initial treatment groups, respectively. The odds ratio of recurrence after treatment was 4.7 (95% CI, 1.4-15; P = 0.011). The secondary and safety outcomes were not significantly different between the two groups. This study showed that the treatment of recurrent sCA was a risk factor for recurrence after treatment but not for additional treatment, rupture after treatment, or neurological worsening. Although decision-making regarding the treatment varies depending on the institutional protocols and personal experience of the physicians, endovascular or surgical retreatment could be performed without hesitation.

Microsurgery of residual or recurrent complex intracranial aneurysms after coil embolization - a quest for the ultimate therapy.

The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.

[Transarterial Embolization of Intraorbital Dural Arteriovenous Fistula:A Case Report].

Intraorbital dural arteriovenous fistula(dAVF)is a very rare disease; therefore, an optimal treatment strategy has not yet been established. Here, we describe a case of successful dAVF treatment by performing transarterial embolization(TAE)with n-butyl-2-cyanoacrylate(NBCA). A 66-year-old male presented with right conjunctival injection, with no history of trauma. Magnetic resonance imaging(MRI)demonstrated a flow void in the right orbit. Digital subtraction angiography(DSA)revealed an AVF fed by a branch of the right ophthalmic artery(OA)and draining into the dilated right superior ophthalmic vein(SOV). A transvenous embolization(TVE)was planned, but it could not be performed because the facial vein was meandering. Hence, TAE with NBCA was performed, and the AVF was successfully occluded by this method. There has been no recurrence of intraorbital dAVF in three months since the treatment. Several recent studies have reported that TAE is an effective treatment for intracranial dAVF. However, there are insufficient reports of TAE with NBCA for intraorbital dAVF treatment. The anatomy of the OA needs to be known for the success of TAE in treating intraorbital dAVF, because TAE is a high-risk treatment. In this paper, we report a case wherein TAE with NBCA was performed for intraorbital dAVF and further review the other treatment options.

Surgical treatment of unruptured distal basilar artery aneurysm: durability and risk factors for neurological worsening.

BACKGROUND: Distal basilar artery aneurysms (DBAs) consist of basilar apex and basilar artery-superior cerebellar artery bifurcation (BA-SCA) aneurysms. The authors aimed to investigate clinical and radiological differences between two locations and to evaluate the 12-month surgical outcome in unruptured DBAs. METHODS: Fifty-six consecutive patients who underwent surgical treatment (37 basilar apex and 19 BA-SCA aneurysms) between April 2012 and February 2016 were retrospectively evaluated. In patients with a preoperative modified Rankin Scale score (mRS) of more than 1, neurological worsening (NW) was defined as an increase in one or more mRS. In patients without symptoms, NW was defined as mRS ≥2. RESULTS: The mean age of the patient population was 64 ± 9.6 years, and 48 (86%) were female. Mean follow-up period was 2.6 ± 0.94 years. An excellent (mRS 0 to 1) outcome was archived in 31 (55%), 45 (82%), and 48 (87%) patients at 30 days, 6 months, and 12 months, respectively. Clinical and radiological characteristics showed no differences between two locations. One early death (1.8%) and one severe morbidity (1.8%) due to rupture were observed. The postoperative annual rupture rate was 1.4% overall (145 patient-years). After adjustment for age and location, large or giant DBA was related to 30-day and 12-month NW [n = 22 (39%) and n = 6 (11%); p = 0.009 and 0.002, respectively], aneurysm localization in the interpeduncular cistern (LIC) and perforator territory infarction were related to 30-day NW (p = 0.002 and 0.002), and DBA that needed bypass surgery and previously treated recurrent DBA were related to NW at 12 months (p = 0.017 and 0.001). Multivariate analysis showed that LIC was significantly related to perforator territory infarction (p = 0.003). CONCLUSIONS: Clinical and radiological characteristics were not different between basilar apex and BA-SCA aneurysms; therefore, they should not be discussed separately. To avoid neurological worsening, results of surgical treatment for unruptured DBAs should be improved.

Olfactory preservation during anterior interhemispheric approach for anterior skull base lesions: technical note.

Anosmia is not a rare complication of surgeries that employ the anterior interhemispheric approach. Here, we present a fibrin-gelatin fixation method that provides reinforcement and moisture to help preserve the olfactory nerve when using the anterior interhemispheric approach and describe the results and outcomes of this technique. We analyze the outcomes with this technique in 45 patients who undergo surgery for aneurysms, brain tumors, or other pathologies via the anterior interhemispheric approach. Anosmia occurred in 4 patients (8.8%); it was transient in 2 (4.4%) and permanent in the remaining 2 (4.4%). Brain tumors clearly attached to the olfactory nerve were resected in the patients with permanent anosmia. We found a significant difference in the presence of anosmia between patients with or without lesions that were attaching the olfactory nerve (p = 0.011). Our results suggested that fibrin-gelatin fixation method can reduce the reported risk of anosmia. However, the possibility of olfactory nerve damage is relatively high when operating on brain tumors attaching olfactory nerve.

Management strategy for bilateral complex vertebral artery aneurysms.

Bilateral complex vertebral artery aneurysms (BCoVAAns) have no established strategy of management. We retrospectively reviewed five consecutive patients with unruptured BCoVAAns between January 2006 and December 2012. Considering surgical risks of lower cranial nerve (LCN) injuries and eventual growth of an opposite side lesion after unilateral vertebral artery (VA) occlusion, we proposed a strategy of combined open and interventional treatment using revascularization. We applied the following several specific techniques: (1) proximal clipping and occipital artery-posterior inferior cerebellar artery (OA-PICA) and/or superficial temporary artery (STA)-superior cerebellar artery (SCA) bypasses; (2) Distal blood pressure, motor evoked potentials (MEPs), and somatosensory evoked potentials (SEPs) monitoring after parent artery temporary occlusion for safe permanent occlusion of the proximal portions of VA and PICA; (3) V3 to V4 bypass using radial artery (RA) graft with proximal clipping or trapping, two of them combined with OA-PICA bypass; (4) VA fenestration as an opportunity to preserve the flow of the parent artery. Two patients were treated bilaterally and 3 unilaterally, with modified Rankin scale assessed at 39 months postoperatively in average 0 in 2, 1 in 2, and 2 in 1, respectively, and the untreated opposite side lesions without regrowth or bleeding. Two patients with patent V3-RA-V4 bypass complained of dysphagia due to LCN palsies. One of them however suffered a cerebellar infarction due to occlusion of the OA-PICA bypass. When BCoVAAns require surgical treatment, revascularization or preservation of the VA should be considered at the first operation. By doing so, the opposite aneurysm can be effectively occluded by coil embolization, even with VA sacrifice if required.

Impact of cervical internal carotid clamping and radial artery graft bypass on cortical arterial perfusion pressure during craniotomy.

Strategic cervical internal carotid occlusion is employed either temporarily or permanently in various neurosurgical procedures. The aim of the present study was to assess changes in cortical arterial pressure during cervical internal carotid cross-clamping before and after the placement of radial artery (RA) graft bypass in the treatment of complex carotid artery aneurysms. Perfusion pressure of the middle cerebral artery (MCA) was assessed in 22 patients with complex carotid aneurysm treated with RA graft bypass. Regional cerebral blood flow was assessed postoperatively using single-photon computed tomography. Mean cortical blood pressure (mcBP) was found to be 48.2 ± 24.2 and 97.0 ± 24.0 % of baseline after clamping the cervical internal carotid artery and opening the RA graft bypass, respectively. Cerebral perfusion pressure estimated by the mcBP failed to sustain a critical limit of greater than 70 mmHg under craniotomy in 16 out of 20 (80 %) patients. There was an inverse correlation in mcBP between the baseline and after the placement of the RA graft bypass (r = 0.66, P < 0.005). Postoperative regional cerebral blood flow in the MCA territory on the ipsilateral side of the aneurysm was 97 ± 7 % of that of the contralateral side after internal carotid artery (ICA) ligation combined with RA graft bypass. Substantial pressure reductions in cerebral cortical arteries were observed during the cervical internal carotid cross-clamping. Perfusion pressure in peripheral cortical arteries after the placement of the RA graft bypass was comparable to the state before ICA clamping.

A Practical Guide to Train the Side-to-side Anastomosis: Tips, Tricks and Technical Nuances.

BACKGROUND: Microanastomosis presents a challenge in neurosurgical procedures, requiring specialized skills. Regular practice outside the operating room is crucial. This study aims to provide a detailed description of the side-to-side anastomosis technique and analyze its advantages in preventing failures compared with other variations. METHODS: We examined the technique, characteristics, and outcomes of side-to-side bypass procedures for complex aneurysms in the anterior cerebral artery territory at our institution over the past decade. We compared our technique with those described in the literature by other groups. RESULTS: The Far East Neurosurgical Institute (FENI) technique was used in 15 patients, with 17 side-to-side anastomoses performed. The average anastomosis time was 27.5 minutes, with 100% patency in follow-up. Our technique demonstrated safety and effectiveness in treating intracranial aneurysms, yielding satisfactory short- and long-term functionality outcomes. We highlight the importance of maintaining a curvilinear arteriotomy shape, at least 3 times the diameter of the artery, and utilizing an interrupted suturing technique on the anterior wall. CONCLUSIONS: This paper presents the first comprehensive description of the side-to-side anastomosis technique, supported with images and videos for training and replicability. Our technique enhances flow dynamics and reduces the risk of acute thrombus formation. Training in simulators and microsurgery practice centers outside the operating room is essential for acquiring and refining microsurgical skills.

Training in Sylvian Arachnoid Dissection: The Art of Using Kamiyama Scissors and a Simple Novel Model for Practice Sylvian Arachnoid Dissection Using Cotton Fiber with Brain Model.

Background Transsylvian approach is one of the main approaches for a variety of vascular, tumor, and skull-base lesions. Sylvian fissure harbors a lot of critical structures including the middle cerebral artery and many venous structures. If not done properly, the transsylvian approach could cause several complications. Up to now, there is no simple training model for practicing Sylvian fissure dissection. In this article, we describe the technique of using microscissors for the sharp dissection of arachnoid trabeculae. We also propose a new model for practicing Sylvian arachnoid dissection using a three-dimensional (3D) brain model with cotton fiber. Materials and Method We inserted cotton fiber into the Sylvian fissure of the brain model (aneurysm box from UpsurgeOn) and covered the Sylvian fissure with a cotton sheet, then sprayed the water over it. We dissected this model under a microscope by using Kamiyama scissors in the right hand and suction in the left hand. Result Under the microscope, our model appears comparable with the real Sylvian fissure. We can use this model for practicing arachnoid dissection with Kamiyama scissors. Conclusion The arachnoid dissection model by using a 3D brain model with cotton fiber is a simplified and novel approach for practicing the Sylvian fissure dissection.

Long-term prognosis in patients with clipped unruptured cerebral aneurysms--increased cerebrovascular events in patients with surgically treated unruptured aneurysms.

We retrospectively investigated surgical immediate and long-term overall results after clipping of the unruptured aneurysms. Between 1991 and 2008, 166 patients underwent neck clipping of unruptured saccular aneurysms at our institute. Patients were subsequently followed to clarify the occurrence of subarachnoid hemorrhage (SAH), and stroke other than SAH, aneurysm recurrence, cerebrovascular death, all-cause death, and risk factors. Surgical complication was noted in 14 patients (8.4%) and surgical morbidity in two patients (1.2%). Of 164 patients except for these two patients who suffered surgical morbidity, we could obtain more than 3 years follow-up information for 144 patients (87.8%). There were 49 men and 95 women. The mean age was 58.5 years, and mean follow-up period was 7.9 years. Eight cases had died during follow-up (hepatic insufficiency in one, renal insufficiency in one, suicide in one, intracerebral hemorrhage (ICH) in two, SAH in one, and pneumonia after stroke in two). Therefore, the cause of death was stroke and late effects of stroke. Twelve symptomatic cerebrovascular events (cerebral infarction in seven, ICH in four, and SAH in one) occurred in ten patients. Consequently, annual risk of SAH after clipping of unruptured aneurysms was 0.085%. Besides, annual risk of stroke in those patients was 1.06%, and this incidence was higher than that in the general population. Although this study confirmed the good surgical result, annual risk of stroke after clipping of unruptured aneurysms was much higher than that in the general population. The long-term periodic examination to detect recurrent aneurysms and appropriate management to prevent stroke should be performed for patients with surgically treated unruptured aneurysm.

A case of anterior choroidal artery occlusion test under MEP monitoring for a recurrent internal carotid artery-anterior choroidal artery bifurcation aneurysm clipping.

A 59-year-old female with recurrent Anterior Choroidal Artery (AchA) aneurysm was elected for surgery at our institution through a standard pterional approach. Two thin perforating branches were found to origin from the dome of the aneurysm during operation, and therefore complete aneurysm clipping preserving these branches was not feasible. These perforating branches were temporarily occluded under motor-evoked potential (MEP) monitoring. The MEPs remained stable during 10 min of temporary clipping, and we concluded that these branches could be sacrificed, and therefore neck clipping was performed occluding these tiny AchA perforators. Although postoperative magnetic resonance imaging with diffusion-weighted images showed ischemic signs in left AchA territory after the operation, the patient remained asymptomatic and was discharged home with mRS 0.

A case of facial nerve palsy caused by severe head injury treated by translabyrinthine approach.

Background: Several treatments for traumatic facial paralysis have been reported, but the role of surgery is still controversial. Case Description: A 57-year-old man was admitted to our hospital with head trauma due to a fall injury. A total body computed tomography (CT) scan showed a left frontal acute epidural hematoma associated with a left optic canal and petrous bone fractures with the disappearance of the light reflex. Hematoma removal and optic nerve decompression were performed immediately. The initial treatment was successful with complete recovery of consciousness and vision. The facial nerve paralysis (House and Brackmann scale grade 6) did not improve after medical therapy, and thus, surgical reconstruction was performed 3 months after the injury. The left hearing was lost entirely, and the facial nerve was surgically exposed from the internal auditory canal to the stylomastoid foramen through the translabyrinthine approach. The facial nerve's fracture line and damaged portion were recognized intraoperatively near the geniculate ganglion. The facial nerve was reconstructed using a greater auricular nerve graft. Functional recovery was observed at the 6-months follow-up (House and Brackmann grade 4), with significant recovery in the orbicularis oris muscle. Conclusion: Interventions tend to be delayed, but it is possible to select a treatment method of the translabyrinthine approach.

Increased PDGFRB and NF-κB signaling caused by highly prevalent somatic mutations in intracranial aneurysms.

Intracranial aneurysms (IAs) are a high-risk factor for life-threatening subarachnoid hemorrhage. Their etiology, however, remains mostly unknown at present. We conducted screening for sporadic somatic mutations in 65 IA tissues (54 saccular and 11 fusiform aneurysms) and paired blood samples by whole-exome and targeted deep sequencing. We identified sporadic mutations in multiple signaling genes and examined their impact on downstream signaling pathways and gene expression in vitro and an arterial dilatation model in mice in vivo. We identified 16 genes that were mutated in at least one IA case and found that these mutations were highly prevalent (92%: 60 of 65 IAs) among all IA cases examined. In particular, mutations in six genes (PDGFRB, AHNAK, OBSCN, RBM10, CACNA1E, and OR5P3), many of which are linked to NF-κB signaling, were found in both fusiform and saccular IAs at a high prevalence (43% of all IA cases examined). We found that mutant PDGFRBs constitutively activated ERK and NF-κB signaling, enhanced cell motility, and induced inflammation-related gene expression in vitro. Spatial transcriptomics also detected similar changes in vessels from patients with IA. Furthermore, virus-mediated overexpression of a mutant PDGFRB induced a fusiform-like dilatation of the basilar artery in mice, which was blocked by systemic administration of the tyrosine kinase inhibitor sunitinib. Collectively, this study reveals a high prevalence of somatic mutations in NF-κB signaling pathway-related genes in both fusiform and saccular IAs and opens a new avenue of research for developing pharmacological interventions.

Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome.

BACKGROUND: The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH. METHODS: Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed. RESULTS: Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04-01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01-01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01-01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63-02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52-0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0-2 and 3-6. CONCLUSIONS: Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.

Sylvian Hematoma Removal after the Stent-Retriever Thrombectomy Accompanied by Arteriole Avulsion: Case Report.

Objective: We describe an instructive case of post-thrombectomy subarachnoid hemorrhage (PTSAH) by sylvian hematoma removal. Case Presentations: An 83-year-old female presented with an acute cardiogenic right M1 occlusion. After the thrombectomy with combined stent retriever and aspiration technique with total five passes, TICI 2b reperfusion was achieved; however, CT imaging displayed subarachnoid hematoma (SAH) along the right sylvian fissure. Throughout the approach, contrast extravasation was not confirmed. The SAH grew up to become the sylvian hematoma; therefore, removal of the sylvian hematoma was conducted. An abrupt arteriole tear around the distal M2 of parietal artery was confirmed as bleeding point and those teared arteriole's stumps were electrically coagulated not to re-bleed. Conclusion: We suggest that the PTSAH is possible even in invisible-extravasation cases and the sylvian hematoma removal is effective to elucidate the etiology of the PTSAH, and is a reliable method to prevent the re-bleeding and is anticipated to improve the prognosis. Craniotomy is required for medically resistant PTSAH after thrombectomy, and avulsion of the pial artery can be the cause.

Management of an Uncommon Complication: Anterior Choroidal Artery Occlusion by Posterior Clinoid Process Detected Through Intraoperative Monitoring After Clipping of Paraclinoid Aneurysm: 2-Dimensional Operative Video.

Despite technological advances in endovascular therapy, surgical clipping of paraclinoid aneurysms remains an indispensable treatment option and has an acceptable profile risk. Intraoperative monitoring of motor and somatosensory evoked potentials has proven to be an effective tool in predicting and preventing postoperative motor deficits during aneurysm clipping.1,2 We describe the case of a 61-yr-old Japanese woman with a history of hypertension and smoking. During follow-up for bilateral aneurysms of ophthalmic segment of the internal carotid artery (ICA), left-sided aneurysm growth was detected. A standard pterional approach with extradural clinoidectomy was used to approach the aneurysm. After clipping, a significant intraprocedural change in motor evoked potential (MEP) amplitude was observed despite native vessel patency was confirmed through micro-Doppler and indocyanine green video angiography.3-5 After extensive dissection of the sylvian fissure and exposure of the communicating segment of ICA, the anterior choroidal artery was found to be compressed and occluded by the posterior clinoid because of an inadvertent shift of the ICA after clip application and removal of brain retractors. Posterior clinoidectomy was performed intradurally with microrongeur and MEP amplitude returned readily to baseline values. Computed tomography (CT) angiogram demonstrated complete exclusion of the aneurysm, and magnetic resonance imaging (MRI) was negative for postoperative ischemic lesions on diffusion weighted images. The patient tolerated the procedure well and was discharged home on postoperative day 3 with modified Rankin Scale (mRS) 0. The patient signed the Institutional Consent Form to undergo the surgical procedure and to allow the use of her images and videos for any type of medical publications.

Microsurgical resection of unruptured cerebellar arteriovenous malformation presenting with trigeminal neuralgia.

Cerebellar arteriovenous malformations (AVMs) represent 10%-15% of all intracranial AVMs and are associated with a greater risk for hemorrhagic presentation compared with supratentorial AVMs. When they reach the cerebellopontine angle cistern, neurovascular compression syndromes, including trigeminal neuralgia and hemifacial spasm, can occur. Due to the aggressive natural history of cerebellar AVM, an effective treatment strategy is required. In this video, the authors demonstrate the technical nuances of microsurgical resection of an unruptured cerebellar AVM in a 24-year-old female presenting with trigeminal neuralgia. The patient underwent right retrosigmoid craniotomy and complete resection of the AVM with resolution of trigeminal neuralgia. The video can be found here: https://youtu.be/6GmNjgFQwx8.