The patient a Syrian citizen, came to the clinic 14-April-2007 complaining slight headache bifrontal in localization with bilateral anosmia.

The patient got sudden loss of consciousness 15-February-2007 and CT-scan performed at that time, showed massive SAH with hematoma both mediobasal frontal lobes, more the right with massive IVH. The patient recovered gradually and carotid angiography done 01.March-2007 showed arteriovenous malformation with wide spread feeders both frontal lobes mediobasal in localization with main feeders coming from the left pericallosal artery and a nidus scattered in the left frontal lobe.

MRI of the brain and MRA were performed later confirming the presence of the nidus in the left frontal lobe.

On examination: The patient had only anosmia both sides with headache fronto-temporal area. He had several attacks of convulsions. The patient is right handed. Slight weakness of the right upper limb without sensory deficit.

The patient was given the options about intravascular embolisation or coiling or direct surgery and the pros and cons were discussed and he preferred direct surgery.

Bifrontal flap was created and bilateral subfrontal approach was achieved. No trail was directed to preserve the olfactory tracts since they were damaged during the primary insult. Massive feeders were originating from the left side of the falx cerebri at the crista Galli. They were coagulated and bisected by sharp microscissors. Interhemispheric approach was done and proceeded down, during which many feeders coming from the right mediobasal and the right pericallosal artery and the falx cerebri anterior third. Dissection was continued until the anterior communicating artery complex was identified and the pericallosal arteries were identified. The right pericallosal artery had no major suppliers to the AVM, in the contrary the left pericallosal artery had two major feeders supplying it, which needed Yasargil clips small size straight Ausculap brand. The arterialized veins regained normal appearance and check for overflow phenomenon was negative after clipping of the major feeders. Inspection of the nidus gave the impression, that there still present another feeders, for what the nidus in the left frontal lobe was removed and the small secondary feeders were coagulated and bisected sharply. The nidus was sent for investigation. The dura was closed water-tight and the frontal sinuses were tamponed by muscle and the bone flap returned in place and routine closure of the wound.

Smooth postoperative recovery and the patient sent to the ICU for observation.

This arteriovenous malformation is not suitable for Gamma knife, neither endovascular maneuvers, because it had plenty of feeders and and big nidus with high flow type.

The best choice for this type of arteriovenous malformation is direct surgery, since the area is functionally is not critical and the already damaged neural tissues by the primary insult will exclude further damage from the surgery.