Late radiation necrosis is a rare entity presenting in 2.2 to 9 % of radiation treated AVMs. It occurs by a mean of 3 years following treatment. There are few reports in the literature of radionecrosis and solid lesions treated with surgery. To the author´s knowledge this case has the longest time interval between radiosurgery and the presentation of cerebral necrosis. In this surgical video, we present the case of a 51-year-old female with a left supramarginal gyrus AVM that received radiosurgery with gammaknife, and after 20 years she started with seizures and aphasia. The MRI revealed a lesion simulating an intra-axial tumor causing important edema and mass effect. Medical treatment was given including high-dose steroids without success, therefore microsurgery was performed. The surgery was presented in a step-by-step basis and correlation was performed with the involved adjacent anatomy, to illustrate the anatomy of the approach and surgical landmarks. The patient symptoms recovered completely, and the postoperative MRI showed complete resection and resolution of the edema. The histopathological findings were consistent with a radionecrosis and AVM. The patient signed the Institutional Consent Form, which states that he/she accepts the procedure and allows the use of her images and videos for any type of medical publications in conferences and/or scientific articles.
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