Right Retrosigmoid Approach for In Situ Occlusion of Brainstem Arteriovenous Malformation Surrounding the Trigeminal Nerve: 3-Dimensional Operative Video

Far Lateral Craniotomy and Occlusion In Situ of a Lateral Medullary Arteriovenous Malformation: 2-Dimensional Operative Video

Lateral medullary arteriovenous malformations (AVMs) are located in the pia on the lateral medullary surface.1 They are supplied by arterial feeders from the V4 segment of the vertebral artery or posterior inferior cerebellar artery. A 64-yr-old man presented with leg spasms and progressively worsening gait. Angiography demonstrated a lateral medullary AVM. Patient consent was obtained for the surgical treatment of this lesion. Owing to its eloquent location, an occlusion in situ was performed without resection.1,2 This technique relies on the interruption of the arterial blood supply and occlusion of the draining vein to occlude the AVM. Intraoperative neurophysiological monitoring of motor and somatosensory evoked potentials was used, and the elimination of arteriovenous shunt flow was confirmed using indocyanine green videoangiography. Occlusion in situ preserves the flow to the delicate brainstem perforators and is safer than resection in selected cases like this one. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

One-staged in situ embolization combined with surgical resection for eloquence protection of AVM: technical note

Brain arteriovenous malformations (AVMs) near/within eloquent areas are challenging to treat surgically. The insufficient lesion-to-eloquence distance (LED) is related to poor neurological outcomes. This paper reports the use of in situ embolization combined with surgical resection in a one-staged hybrid operation for eloquent area protection. Nine patients who underwent one-staged in situ embolization combined with surgical resection were selected from the database of a prospective clinical trial (NCT03774017). Nidus got partial in situ embolization in the parts located near/within the eloquence. The rest of nidus was removed via a microsurgical procedure in the same operation. The in situ embolization ensured a sufficient LED to prevent eloquent areas and tracts from being damaged in the subsequent resection. All of the patients achieved complete obliteration with no neurological deficits or complications. One-staged hybrid operation initiates closer cooperation between surgical and endovascular treatments and proposes an integrative therapeutic mode for AVMs. The in situ embolization combined with surgical resection is safe and effective for improving the functional outcome of AVMs with eloquence and tracts involved. The clinical trial is registered at ClinicalTrials.gov (NCT03774017, https://clinicaltrials.gov/ct2/show/NCT03774017 ).