The Hurt Locker

Arteriovenous malformation (AVM) resection should be an interesting and comfortable operation to perform. Nowhere else in neurosurgery will you find such a strange assortment of tangled arteries that can be dissected and then obliterated with ischemic impunity. But that interesting and comfortable operation for the surgeon can quickly turn into a “hurt locker,” which is military slang for a period or place of immense, inescapable physical or emotional pain, such as trying to disarm an improvised explosive device. Resecting an AVM is like defusing a bomb, picking it apart wire by wire, artery by artery. One mistake and the AVM will detonate in front of you. The threat of explosive hemorrhage adds stress and tension to the operation. Following a draining vein to the nidus can compromise outflow or rupture it; misjudging the right dissection distance can injure eloquent brain; and perforators on the ependymal plane can be nasty. Bleeding is unavoidable, even without technical mistakes, even with a new pair of nonstick bipolars, and even when microclips are deployed correctly. Part of successful AVM surgery is not expending too much time and energy on uncontrolled bleeding.