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Lateral Temporal AVM: Handling en passage Arteries

April 29, 2016


This video describes the importance of preserving the en passage vessels during resection of arteriovenous malformations and in this case, a lateral right temporal AVM. This is a 32 year-old male who presented with a spontaneous right temporal intercranial hemorrhage. He was previously diagnosed with an arteriovenous malformation and he elected to expectantly follow the lesion. At the time of the hemorrhage further imaging was performed including a CT angiogram. You can see the angio architecture and the location of the malformation as well as the relationship of the hematoma with respect to the lesion. An angiogram further studied the arterial feeders from the MCA branches and the draining vein which is primarily the vein of labbe. You can also appreciate other feeding vessels from their posterior temporal branches. He underwent a right temporal craniotomy for resection of the mass. Linear incision was used. Again this is anterior, this is posterior. This is the floor of the middle fossa. A linear incision was utilized. A limited craniotomy was elevated and a dura was opened in a cranial fashion based over the middle fossa. You can see the arterialized vein of labbe, multiple feeding arteries leading to the malformation. The hematoma is located here. The malformation is hidden within this sulcus. And obviously the fate of this large feeding vessel has to be determined upon further dissection of the nidus. Let's go ahead and open the arachnoid bands in the area and specifically around the arterial feeders, to be able to follow the artery and more specifically recognize those vessels directly feeding the nidus. Obviously these large vessels have to be preserved. The nidus has to be carefully isolated and only those specific vessels that are feeding the malformation should be sacrificed. We use the transulcal technique at the beginning and small corticotomy was also necessary to further uncover the malformation. Now I follow the vessel to the nidus. I expect to discover multiple small feeding vessels to the nidus. These cork screw style vessels are characteristic of those feeding the malformation. The transulcal technique was connected to it. Transcortical technique in order to carefully identify the malformation. Here you can see part of the nidus. These corkscrew vessels obviously are from the surrounding larger vessels. These ones should be sacrificed. The larger vessels that appear normal, such as this one demonstrated here, should be preserved. This larger artery that you saw within the sulcus is primarily an en passage vessel with corkscrew vessels leading to the nidus. The hematoma was subsequently encountered. It was evacuated. Can I suspect the malformation to be just inferior to the pole of the hematoma? Here's a more demagnified view of our operative corridor. Again these corkscrew vessels to the malformation are coagulated and cut. The nidus is more apparent now. The deep white matter feeders to the malformation are coagulated and cut. Some bleeding is encountered which is not unusual from these deep white matter feeding arteries. I continue circumferential disconnection of the nidus. Stay outside of the nidus to avoid any significant bleeding. Now the posterior part of the nidus is being disconnected. Here's a feeding vessel leading to the AVM. This is most likely the continuation of the larger vessels or the larger vessel that I initially discovered. I continue to skeletonize the larger vessel and only sacrifice the corkscrew arteries leading directly to the malformation. Here you can see a corkscrew branch leading to the nidus. It's being disconnected. Additional feeding vessels to the AVM are apparent. Here's the nidus. Here's the en passage vessel. Again I continue to skeletonize the en passage vessel. You can see the corkscrew vessel leading to the nidus. Stump of the artery is left on the main branch to avoid any injury to the en passage artery. Most of the nidus is now disconnected. Here's the last part of the AVM that I'm not disconnecting. These corkscrew vessels have to be carefully coagulated before they're cut to avoid their bleeding. You can see the vein of labbe is darker now. The nidus is being delivered. The last feeding arteries are now disconnected. You can see that the vein of Labbe is getting darker and darker. It's evident that the corner of the operative field, I continue to persist fight these deep white matter feeders at the apex of the malformation so that the AVM can ultimately be extracted. The AVM now appears free. It's connection to a straining vein is now disconnected. Another small piece is also removed. Further inspection reveals no residual nidus. You can see that the en passage vessel is intact. Obviously this is important to avoid any distal ischemia. Vein of labbe is now completely dark and venus. And the post operative CT scan excluded any complications and the post operative angiogram confirmed complete exclusion of AV shunting. Thank you.

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