Background: Cerebral arteriovenous malformations (AVMs) are rare, with incidence of 1.12-1.42 cases per 100,000 person-years(1). Few studies report applications of awake surgery. The goal of this report was to assess the interest of awake surgery in complete resection of cortical AVMs located close to eloquent speech areas, enabling detection of real functional cortical reorganization due to the AVM and parenchymal hematoma.

Case report: A 38-year-old right-handed patient was admitted to the University Hospital of Besançon for dysphasia due to a ruptured left temporal arteriovenous malformation. The patient underwent asleep-awake-asleep surgery. Intraoperative cortical mapping revealed the presence of functional language areas in uncommon locations compared to known neuro-functional anatomy.

Discussion: In this patient, speech areas were redistributed, probably due to neuroplasticity after cerebral hemorrhage, leading to a new cortical architecture, which would have been unrecognized based on preoperative radiological imaging alone.

Conclusion: We report the interest of awake surgery to achieve complete safe resection of ruptured AVMs located close to eloquent speech areas, using intraoperative cortical mapping.