Frontal Sylvian AVM and Pedicle MCA aneurysm

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This video describes techniques for Resection of Arteriovenous malformations and Clip Ligation of Associated Feeding Pedicle Aneurysms. This is a 42 year-old female who presented with seizures and on imaging was found to have a right frontal Sylvian arteriovenous malformation associated with a broad-base feeding pedicle aneurysm at the level of the anterior temporal artery. You can also appreciate the large draining veins located over the area of the Sylvian fissure. Here's additional images demonstrating the angioarchitecture of the malformation and associated large draining veins, as well as the multilobular morphology of the pedicle aneurysm. Right frontal temporal craniotomy was completed. Here's the right temporal lobe, right frontal lobe, multiple arterialized veins over the Sylvian fissure. The fissure was widely dissected. The arterialized veins harbor robust walls and can be gently manipulated without significant risk. Sharp dissection is continuously used. You can see the very prominent arterialized veins within the very busy and crowded Sylvian fissure. Slight bleeding from the feeding vessels during dissection can be controlled patiently without injury to the primary draining veins. Indiscriminate coagulation is quite risky. Irrigation is used. Next, I continue my dissection so that the feeding vessels from the MCA to the arteriovenous malformation are identified. M1 is skeletonized and the aneurysm is exposed. Here are some of the M2 trunks. Some of the frontal branches are more specifically targeted. Here's the aneurysm. The M1 is more proximal. I felt that the permanent clips can potentially interfere with resection of the malformation and placement of temporary clips on the feeding vessels to the AVM. Therefore, the AVM was managed first while proximal control of the aneurysm was available. The Sylvian was somewhat bloody specially along the white matter feeders, along the posterior pole of the malformation. I think I could have avoided this situation and some bleeding by managing the Sylvian feeders first. Nonetheless, bleeding was controlled. My rationale was first to dissect AVM as much as possible more superiorly, so that the feeding vessels can be more clearly identified. Here you can see some of the frontal branches of the MCA territory leading directly to the malformation. I did not exclude these feeders definitively until I carefully dissected them around their routes to make sure that they do not contain any envisaged vessels. Some of the fine vessels there were unquestionably leading to the malformation were disconnected. Other feeding vessels are being identified. And their identity is quite clear that they are leading to the malformation and are not envisaged vessels. A permanent clip is placed on some of the larger ones. The draining vein is temporarily occluded. The AVM remained relaxed and therefore the malformation was extracted after the vein was disconnected. So now you can see the area of the aneurysm, the bifurcation, some of the frontal branches that were envisaged, temporal trunk and the avian feeding pedicle that was disconnected to allow removal of the malformation. Let's now go ahead and address the aneurysm. Obviously the anterior temporal artery, which is hidden behind the aneurysm neck, should be identified. A tentative clip was initially placed so that I can work around a deflated neck of the aneurysm to carefully identify the origin of the anterior temporal artery. Clip was gradually closed. Here now, the origin of the anterior temporal artery is apparent. Its origin is more distal along the neck of the aneurysm than initially thought. And that's why the temporary clip is so useful to deflate the aneurysm and further identify the origin of the anterior temporal artery. Second trial of definitive clip revealed complete exclusion of the neck, but the origin of the anterior temporal artery was at risk. Therefore a tandem clip was placed just distal to the first one and the first clip was removed. Postoperative CT scan reveals no evidence of significant ischemia and postoperative angiogram demonstrates complete exclusion of the malformation as well as the aneurysm. Thank you.

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