Transcript

Here is another video describing the techniques for a section of a lateral posterior temporal arteriovenous malformation. This is a young patient who presented with spontaneous intracranial hemorrhage, underwent a left-sided craniectomy in the outside institution. This procedure was performed obviously emergently. Subsequently a CT angiogram demonstrated the presence of the arteriovenous malformation just anterior, as well as superior to the hematoma cavity. Cerebral arteriogram demonstrated the vascularity of the malformation in the feeding vessels, from the inferior division of the MCA to draining vein, most likely a hypertrophied vein of labbe. As expected there is also numerous group of feeding vessels from the posterior circulation, including the PCA. Patient underwent reopening of the craniotomy, you can see the middle fossa floor. Again, a left-sided approach, the draining vein. The hematoma cavity was entered. I expect the malformation to be located here. After evacuation of the hematoma, I continued circumferential disconnection of the malformation anteriorly. Here's another view of the procedure for evacuation of the clot. Here's the arterialized draining vein. This vein was protected. I worked on both sides of the vein via two corticotomies so that the hematoma is adequately removed. Next, I exposed the branches from the inferior division of the MCA so that these dominant feeding vessels can be excluded during the initial phases of the operation. You can see the leash of vessels from the MCA feeding the nidus of the malformation located here. The magnified view of the operative corridor to orient true regarding different phases of the operation. So the nidus is being disconnected more superiorly first. Here's another feeding artery from the MCA. The draining vein remains very arterialized. Here's the temporal horn, the feeding vessels through the ventricles or in other words the choroidal vessels that are leading the two malformation are coagulated and cut. So now I'm working on the medial aspect of the nidus. You can see the malformation is being mobilized laterally. You can see that the temporary occlusion of the vein lead to swelling of the malformation making me believe that there are residual feeding arteries going into the malformation. Here's another feeding vessel that is being sacrificed. The vein is now more blue, its temporary occlusion reveals no further swelling of the nidus. Therefore, the draining vein was coagulated and cut. Here's the temporal horn, choroid plexus, no residual malformation leading to the ventricle. Here is the final product. Postoperative angiogram demonstrated complete exclusion of the malformation and this CT scan revealed no unexpected findings. And this patient made an excellent recovery. Thank you.

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