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

Complete angiographic obliteration on initial angiography after microsurgery was achieved in 97.5% of navigation-assisted bAVM resections.

• 154 of 158 consecutive navigation-assisted resections showed complete obliteration on initial angiography.
• Cohort comprised Spetzler-Martin grades I-V.
• All resections were performed by a single neurosurgeon from 2013 to 2025.

Most patients were functionally independent at follow-up.

• 93.0% of patients had mRS score 0-2 at a median follow-up of 15 months.
• Outcomes were assessed relative to baseline mRS.

Postoperative increases in mRS score were common but mostly minor, whereas loss of independence and mortality were low.

• mRS increase relative to baseline occurred in 18.4% of patients, most commonly minor, nondisabling deficits with preserved independence.
• Loss of independence attributable to surgery occurred in 3.1% of patients.
• Mortality rate was 1.3%.

The study cohort was drawn from a larger consecutive series, with 158 of 192 bAVM resections being navigation-assisted.

• 192 bAVM resections were performed during the study period (2013-2025).
• The 158 navigation-assisted resections formed the analytical cohort and spanned SM grades I-V.

The workflow integrated multimodal imaging fusion with segmentation of all angiographically identifiable feeders as prioritized operative targets.

• Datasets were assembled from CTA, high-resolution structural MRI with thin-slice T2-weighted imaging, MRA, and 3D rotational DSA according to clinical relevance and availability.
• Images were fused within standard clinical neuronavigation platforms.
• Feeders were segmented along surgically relevant courses and incorporated into exposure and corridor planning.

Targets were displayed intraoperatively via the available navigation configuration, including microscope-based AR as the technology evolved, with selective fMRI and DTI integration for lesions near eloquent anatomy.

• fMRI and DTI were coregistered selectively to provide cortical and tractographic context.
• The goal was to identify and target arterial feeders before substantial nidal dissection, supporting early proximal arterial control even for deep or obscured feeders.

The authors conclude the workflow was feasible across SM grades and provides a structured framework for planning, execution, and teaching of feeder-directed bAVM microsurgery.

• The workflow translates preoperative angioarchitecture into a planned sequence of discrete intraoperative arterial targets in structural and functional context.
• The results are described as 'associated with' high obliteration and independence rates, from a single-surgeon, consecutive series.