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

Abstract

Abstract Arteriovenous malformations (AVMs) of the trigeminal root entry zone are rare and can be associated with neurovascular compression syndromes as well as intracranial hemorrhage.1 They generally have a small nidus located on and around the pial surface of the brainstem; thus, they are feasible for surgery. Nevertheless, they represent a challenge given the vicinity and involvement of cranial nerves and brainstem perforators.2–4 This video demonstrates the case of a 57-yr-old man with new onset of a severe headache without neurological deficit associated with MRI evidence of a vascular malformation around the cisternal right trigeminal nerve. The nerve showed an altered signal on the MRI. Angiography revealed a Spetzler–Martin grade II AVM with a 16-mm nidus supplied by basilar artery perforators, right anterior inferior cerebellar artery, and the superior cerebellar artery (SCA), with drainage into the superior petrosal vein and sigmoid sinus. After an unsuccessful attempted embolization, the patient was referred for and elected microsurgical treatment. With the patient in a lateral position, a right retrosigmoid approach was performed. After cisternal dissection and identification of the nidus, the feeders were occluded by alternating cauterization and clipping to avoid damage to the critical surrounding structures. The AVM in-situ occlusion was carried on without resection, given the involvement of the trigeminal nerve. The intraoperative indocyanine green angiography allowed recognition of the venous drainage and helped to localize and differentiate the feeders from normal perforators. In the immediate postoperative course, the patient suffered from mild numbness with a V2-V3 distribution that progressively improved. Angiography showed no residual AVM.