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Occult AVM nidus in symptomatic left temporal arteriovenous malformations: operative management strategies in two sister cases
  1. Gregory Glauser,
  2. Jared M Pisapia,
  3. Matthew Piazza and
  4. Omar Choudhri
  1. Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Gregory Glauser, Gregory.glauser{at}uphs.upenn.edu

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Description

These sister video cases present some unique technical tenets for the microsurgical resection of left temporal lobe arteriovenous malformations (AVMs) with varied presentations (figure 1, video 1). The first patient described in this case is a 52-year-old man with a history of sudden headache with word finding difficulty, who was found to have a 4×2.5 cm intraparenchymal haemorrhage within the posterior left temporal lobe on radiographic studies. Initial angiography at an outside hospital did not identify the AVM nidus subsequently seen on follow-up angiogram, which illustrates the need for interval angiograms in these cases. The second patient described is a 58-year-old man with a history of hypertension, who presented to an outside hospital with seizures and vision changes. On arrival, the patient had expressive aphasia and a deficit in the right visual field. Imaging showed thrombosis of a draining vein associated with an AVM near the left transverse sinus. Both patients underwent microsurgical resection involving a left posterior temporal craniotomy, stereotactic navigation, intraoperative angiography and indocyanine green (ICG) monitoring. For patients with AVMs and outflow thrombosis, such as the latter case, microsurgical resection is the preferred treatment modality.

Figure 1

Operative view of temporal lobe arteriovenous malformation.

Video 1

Microsurgical resection of two symptomatic left temporal lobe arteriovenous malformations (AVMs). AVM; AVM resection; intracranial haemorrhage; cerebrovascular.

Learning points

  • Arteriovenous malformations (AVMs) can present with haemorrhage, as well as oedema, especially if the venous outflow gets thrombosed in the latter case.

  • Temporal lobe AVMs can be symptomatic with speech, vision and spatial deficits following haemorrhage or venous occlusion of an AVM.

  • In the setting of temporal lobe haemorrhage and the absence of clear nidus, it is important to assess subtle angiographic features with early venous drainage to diagnose occult AVMs.

  • Principals of AVM resection include disconnection of arterial feeders before venous occlusion.

Footnotes

  • Contributors All authors involved in preparation of the video concur that no work resembling the enclosed video has been published or is being submitted for publication elsewhere. We certify that each of us have made a substantial contribution as to qualify for authorship as follows: OC, JMP and MP performed the procedures, OC provided video narration, GG performed critical video editing and preparation for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.

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