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Ruptured Sylvian/Insular AVM

August 14, 2016


Here's a case of a Sylvian arteriovenous malformation, that had ruptured. This is a 52 year old male who presented with a spontaneous intraparenchymal hemorrhage within the posterior temporal lobe, as demonstrated on the CT scan. Cerebral arteriogram showed evidence of a posterior insular malformation with a number of small feeding vessels from the M2 branches. There is a large draining vein traveling more superficially as well as anteriorly. Here is a CT angiogram also demonstrating the location of the malformation and within the posterior Sylvian fissure. The hematoma is inferior and more medial and lateral compared to the malformation. There's at least one hypertrophied M2 branch, that is very closely related to the AVM. Here's the generous right frontotemporal craniotomy. There is a superficial arterialized vein, that is immediately apparent. I made a court economy within the posterior superior temporal gyrus, so that the hematoma can be entered and further grow in relaxation secured. Next, the Sylvan fissure was dissected, proximal control and exposure of the M2 branches was possible. Here are some of the M2 branches leading to the malformation. I follow these M2 branches more posteriorly within the fissure. This is most likely the dominant M2, the hypertrophied one, leading to the cork school vessels that join the nidus. Now there are two operative corridors, one within the hematoma cavity, and one within the Sylvian fissure. Working within the hematoma cavity, further hematoma evacuation was secured. The AVM should be located just about here. hematoma is available for removal. Irrigation may be used to dislodge some of the clots. Again, two operative corridors, one within the fissure, one within the hematoma cavity. Nidus located here. I go ahead and disconnect the more inferior aspect of nidus within the incision into the hematoma cavity. Now I divert my attention within the posterior aspect of the Sylvian fissure, where the corkscrew vessels are found and disconnected. Here's part of the nidus coming back into the poster Sylvian fissure. You can appreciate these small feeding vessels from the M2 into the nidus. Obviously, only the feeding vessels to the nidus are removed and emphisage vessels protected. Please recognize the corkscrew appearance of the small feeding vessels to the malformation, they appear swollen, corkscrew and intimately involved with the nidus. Here is a leash of feeding vessels to the malformation. Here's another view of the nidus through the hematoma cavity. M2 trunks are protected. Again, another group of feeding vessels to the malformation. Essentially, I'm skeletonizing the M2 branches within the fissure while protecting their emphisage smaller branches. Now you see the distal M2 branches. Most of their smaller feeding vessels to the malformation is disconnected. Another group of feeding vessels to nidus. There are numerous groups of these feeding vessels to the nidus, that is now located here. Here's the disconnection portion of the nidus the draining vein that is located superficially, is now much darker. No obvious residual malformation is apparent. In here's that dark and draining vein. M2 trunks appear intact. The resection cavity is carefully inspected. Postoperative angiogram revealed complete exclusion of the malformation with preservation of all the M2 trunks. Here's the lateral view of the internal carotid artery injection, as well as the AP view. Post operative MRI at three months, reveal no evidence of ischemia. This patient significantly recovered from his semi-paralysis and has done extremely well. Thank you.

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