June 09, 2015
Cingulate or callosal arteriovenous malformations are relatively rare. This is a 41 year old male who was diagnosed with an incidental malformation within the cingulum and partly within the corpus callosum. You can see the draining vein within the interhemispheric space. The malformation is relatively small. He subsequently underwent an angiogram to better define the angio-architecture of the malformation. As expected, the malformation is primarily fed by the branches of the pericallosal arteries with a draining vein joining the inferior sagittal sinus. There's also some feeding vessels through the corpus callosum. Patient underwent resection of his malformation via a right parasagittal and pteri-frontal craniotomy. The interhemispheric space was entered. A lumbar drain was placed at the beginning of the operation. Here's a normal appearing vein over the left cingulum. Again, we're using a cross-court approach. Going from the right side to resect the lesion on the left side. Here's the feeding vessels from the pericallosal arteries to the malformation. I start with disconnecting the feeders along the inferior margin of the malformation. Next, the malformation is circumferentially dissected. Obviously, they're posteriorly traveling. Arterialized vein is carefully protected. Here's the nidus southern malformation. Here's a normal appearing vein. Again, this is the arterialized vein located more superficially, draining into the inferior sagittal sinus. I suspect that there will be some bleeding from the deep white matter feeders within the corpus callosum. Some of the superficial cortical vessels are quite easy to control and this part of the operation can proceed quite efficiently. I enter the white matter of the cingulum and continue to circumferentially disconnect the malformation, staying just on the border of the malformation. Here's disconnection of the malformation from some of the feeding vessels from the left pericallosal and callosum marginal arteries. Again, en-passage vessels are carefully protected. More bleeding from the deep white matter feeders from the contralateral side. Again, every vessel is carefully inspected before sacrificed to make sure that en-passage vessels are protected. As I continue to dissect the malformation toward the callosum, more bleeding from the deep white matter feeders was encountered. It appeared that I may not be circumferentially disconnecting the malformation and may have actually entered the nidus inadvertently. During this phase, I continued to disconnect the malformation as efficiently as possible. Gentle tamponade was also used in the case of slow arterial oozing. Some of the other feeding vessels to the malformation were found. The section planes were maintained using small cotton patties. I continued sharp dissection, staying right at the periphery of the malformation. Here are some of the final feeding vessels from the anterior border of the malformation facing the corpus callosum. The nidus finally was delivered. Here's the contralateral pericallosal artery. One of the cotton patties was removed. Slight bleeding from the contralateral pericallosal arteries apparent. The best method to control this bleeding is to use a piece of cotton to wrap the vessel. The cotton may be soaked in thrombin and very gentle tamponade can be quite effective so that the vessel is not further manipulated and injured. Here's the piece of cotton. Gentle pressure and some patience do magic. Here's irrigation of the operative field using thrombin solution. Good hemostasis was secured. Intraoperative angiogram demonstrated complete exclusion of the malformation. Three months MRI as well as CT angiogram also excluded any presence of malformation. There was no evidence of complicating features or ischemia on these imaging modalities. Thank you.
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