This is a good learning video regarding Management of Intraoperative Hemorrhage and Resection of Diffuse Arteriovenous Malformations. This is a 32-year-old female who presented with intractable seizures, and on MRI valuation was diagnosed with a colossal or a cingulate, arteriovenous malformation with a large draining vein within the ventricle draining more posteriorly. As expected she underwent, a pre-operative angiogram which demonstrates, the morphology of the malformation with a large draining vein located within the ventricle. The of the aneurism is relatively diffused in this case, however I expected that neither is true and just about in this location. As you'll see in this intraoperative video, the malformation appear to extend more posteriorly. This malformation is located in the left cingulate gyrus, and left part of corpus callosum. And right parasagittal craniotomy was performed so that a cross core trajectory can be used across the falx via the transfalcine approach to reach the malformation. This transfalcine or cross court trajectory, provides an extended, operative corridor, toward the lesion. Here you can see, a hypertrophied, a two branch, or pro closeup branch leading to the malformation. Here's the malformation, small amount of embolic material, again the draining vein is located within the ventrical, and is much deeper. Lumbar drain was placed at the beginning of the procedure, all the embassage vessels, are carefully identified via dissection of the arachnoid bands. Here's the Corpus callosum. Here you can see the Corpus callosum and the feeding vessels to the malformation. Here's the pericallosal branch leading to the malformation, this is a embassage vessel, the falx lubrie was then transected, and a window was created through the falx to expose the contralateral, cingulate gyrus more effectively. Again en passage pre-cal branch feeding artery to the arteriovenous malformation. The falx is reflected superiorly. Part of the malformation is evident as a tip of the arrow. Switch is placed within the falx to keep the edges of the falx out of the operative corridor. I started my dissection around the pericallosal arteries to be able to de vascularize the malformation from its feeding pedicles early on. Here's another view of the malformation incorporating the Corpus callosum and part of the cingulate gyrus. Here's the dissection on the malformation through the Corpus callosum. This was quite diffusing, owned and matter of deep white matter feeders that were quite difficult to control, nonetheless I persisted and also disconnected their large pericallosal branch, leading to the malformation. I'm working now along the interior border of the malformation with some of the embolic material that can assist as intraoperative navigation when compared to the findings on preoperative imaging. Corpus callosum, some of it deep white matter feeders again. Now I'm, dissecting the as more laterally, so it can be disconnected from the white matter tracks of the cingulate gyrus, depending on the ventricle, it's more evident. I continue to disconnect the malformation through the Corpus callosum. Relatively clean and pretty AVM margin. Now more posteriorly and disconnecting the malformation from the draining vein entering the ventricle. You can see the draining vein at the tip of the arrow and they're bipolar forceps. Here's the ventricle. It appears that I'm at the posterior edge of the malformation, both based on interoperative navigation and margins of parenter. The vein has been disconnected. I continue to isolate them all malformation from is posterior. And however, further dissection revealed some bleeding from the posterior white matter, which led me believe there is potentially a residual ABM along the poster porter of my dissection. Therefore, I continued to expand the border of dissection more posteriorly, The lack of ability to achieve immediate hemostasis most likely means the presence of residual. Hemostasis is only attained upon removal of that. So the falx was further mobilized. You can see the part of the night that was overlooked. The brain appeared also swollen in this area. Another important finding, which led me believe some residual is present. You can see this part of the is being disconnected and circumferentially isolated. Some of the white matter feeders are quite strong, and are bleeding. I follow the white matter feeders slightly away from the so that they're relatively more normal wallace found in quiet elated. Here's dissection of the poster part of the malformation from some of the feeding vessels from the pre-colonial arteries. As part of the malformation and dissection was quite bloody it's best to stay as much out of the and outside the margins of the malformation to avoid the bleeding. Here's the quiet collation of the feeding vessels from the precocial arteries. This part of the malformation is now better defined. Some of the feeding vessels from the Corpus callosum are being disconnected. Here's the connection of this part of the malformation to the draining vein. That is being also sacrificed. The resection appears much drier. This part of the malformation was also removed. A temporary clip was placed in there resection cavity, so that in an intraoperative angiogram can be performed to assure complete exclusion of their malformation. The postoperative angiogram in this case confirmed complete exclusion of the malformation without any complicating features. And this patient recovered from her operation very nicely and has remained seizure-free. Thank you.
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