Basal Frontal AVM: Principles of Resection

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This video is a nice demonstration of a resection of a large basal frontal arteriovenous malformation. This is a 48 year-old male who presented with seizures. MRI evaluation revealed the location of the malformation along the left.. Sub-frontal or basal frontal lobe leading to the ventricle. An angiogram characterize the angio architecture of this Basilar funnel Arteries malformation, as expected the malformation was primarily fed from the branches of the middle cerebral artery as well as the anterior cerebral artery with a draining veins, moving both anteriorly and posteriorly within this sub-frontal area. A left front temporal craniotomy was performed in standard fashion. You can see the extent of the craniotomy. In this case, an orbital psychosomatic osteotomy was deemed unnecessary. I flattened the roof of the orbit after the Douro was mobilized. The boney gyrations were drilled flat, so that an unobstructed sub-funnel operative trajectory can be attained. Can see the craniotomy is primarily frontal here's the Sylvian fissure after dural opening, the latter aspect of AVM is apparent. The anterior limb of the Sylvian fissure is carefully dissected, You can see the arterialized veins within the surface of the Fissure. The arachnoid bands, over the optical carotid systems were opened to drain additional CSF. Furthermore, dissection of these arachnoid bands further mobilized the frontal lobe away from the anterior cranial fossa. Here's the carotid artery, optic nerve carotid artery And the AVM is readily apparent. Here are the feeding branches from the MCA. These branches will be coagulated first as these are the primarily feeding vessels to the malformation based on pre-operative angiogram. Obviously all the draining veins are carefully protected. I continue to disconnect the malformation along its posterior border, just in front of the Sylvian fissure. Here's a large draining vein. Again, joining the Sylvian vein toward the sphenoparietal sinus, Obviously this draining vein has to be carefully protected. There's usually a very dominant feeding artery associated with the vein that should be coagulated. Here's the disconnection of the malformation more medially again, staying out of the Nidus here's that draining vein that is being protected. Here's another draining vein, all their arachnoid bands are dissected so that their identity of the arterial feeders and drain veins are clearly demonstrated. Here's another draining vein joining their superficial Sylvian vein, that is arterialized. Now I'm going to disconnect the malformation more laterally along the sub-frontal area. Here's a more magnified view of our operative corridor. Further opening of the arachnoid bands will allow curve for inspection of the true anterior Porter of the malformation. You can see fix retractors are unnecessary. Here's the opening of their arachnoid bands. Here's the disconnection of the malformation More medially, I continue to circumstantially disconnect the malformation Here's an arterial feeder. Joining the malformation. The cortical feeding vessels are readily responsive to bipolar coagulation. However, the deep white matter feeders act otherwise. Now that the appeal dissection phase or the appeal diverticularization phase is complete I'll continue to circumstantially and in a spiral fashion disconnect the malformation from their surrounding white matter. If some of the cortical feeding vessels, more anteriorly are being disconnected. You can see each one is carefully isolated, coagulated and cut. Perilesional white matter is apparent, it can continue to disconnect the malformation circumstantially, protecting the draining vein coming out of the nidus. Now deepening.. and disconnecting the malformation within the white matter. This dominant draining vein is protected. I work on both sides of the vein to disconnect the malformation, and most importantly, defeating vessels. This draining vein appears darker, which is obviously good news. Here's the border of the malformation. Some of the deeper white matter feeders you can see, they appear very thin walled and may not always be amenable to bipolar coagulation. A more de-magnified view as I continue circumstantial disconnection of the malformation. Bleeding is minimized, as long as I stay outside of the nidus. Here's very clearly, deep white matter feeder, very thin walled. This one was relatively amenable to bipolar coagulation, You can see the draining veins are becoming darker and darker, as I continue the disconnection. Temporal occlusion of this vein reveal Northern and south lesional swelling here is another draining vein that's still patent. Since one draining vein was functional. I went ahead and disconnected this one, since most of the malformation is disconnected. So I can mobilize the lesion more effectively after the malformation was completely isolated. The last draining vein was also disconnected. The disconnected nidus was removed. You can see the final result. All the veins are dark now along the surface and the Sylvian fissure. And here's a post operative angiogram, which demonstrates no evidence of Arteriovenous shunting, there is some in Gorge arterialized vessels tore the malformation by no evidence of AV shunting and this patient made an excellent recovery. Thank you.

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