Abstract
Approximately 10-30% of brain arteriovenous malformations (AVM) have associated arterial aneurysms (AAA), and the management of these lesions can be challenging. In this video technical note, we demonstrate the microsurgical treatment of an unruptured, Spetzler-Martin grade I AVM in the distal Sylvian fissure with two AAAs arising proximally from the inferior M2 trunk immediately distal to the middle cerebral artery (MCA) bifurcation. First, we resected the superficially located AVM to normalize the blood flow through the Sylvian vein. Next, we performed a Sylvian fissure dissection to access and clip the two MCA AAAs. We also discuss the technical nuances of tandem surgical intervention for AVMs with AAAs as it pertains to this case, particularly with respect to the order of lesion treatment, Sylvian fissure dissection, nidal resection, and aneurysm clipping.
Highlights
Brain arteriovenous malformations (AVM) harbor associated aneurysms arising from feeding arteries in approximately 10-30% of cases [1, 2]
We describe the concurrent surgical treatment of a distal Sylvian AVM with two proximal prenidal arterial aneurysms (AAA) arising in the vicinity of the middle cerebral artery (MCA) bifurcation
Conservative management was considered in our patient, due to his old age and lack of prior AVM hemorrhage, we decided to offer intervention based on two factors: (1) the presence of an AAA has been shown to increase an AVM’s hemorrhage risk [1, 13, 14], and (2) the patient presented with AVM-associated seizures, which can be ameliorated or abolished upon nidal obliteration [15,16,17,18,19,20]
Summary
Brain arteriovenous malformations (AVM) harbor associated aneurysms arising from feeding arteries in approximately 10-30% of cases [1, 2]. Proximal prenidal AAAs may be located distant to the AVM, such that dissection of the nidus does not expose the AAA These uncommon lesions pose unique challenges to the cerebrovascular surgeon. In this technical note, we describe the concurrent surgical treatment of a distal Sylvian AVM with two proximal prenidal AAAs arising in the vicinity of the MCA bifurcation. How to cite this article Ding D, Buell T J, Raper D M, et al (February 07, 2018) Sylvian Arteriovenous Malformation Resection and Associated Middle Cerebral Artery Aneurysm Clipping: Technical Nuances of Concurrent Surgical Treatment. Narrative video describing the technical nuances of concurrent surgical treatment of an unruptured, right-sided Spetzler-Martin grade I AVM of the distal Sylvian fissure with two proximal prenidal AVM-associated aneurysms arising from the inferior M2 trunk immediately distal to the MCA bifurcation. The patient had an uncomplicated postoperative course, and was discharged home on postoperative day 7 without focal neurological deficits
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