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Complex Vermian AVM

October 28, 2019


This is a video describing the techniques for resection of a superior Vermian AVM that actually has two components and using intra-operative fluorescence for guidance. This is a 53 year old person who presented with subarachnoid hemorrhage. CT angiogram demonstrated a superior variant AVM. As you can appreciate here a large draining vein and also potentially another AVM located a little bit more along the inferior aspect of the cerebellum. Angiogram demonstrates the angio architecture of the malformation. Again, the superior vermin AVM, draining vein and also another Knight is located here and has an associated draining vein as well. The feeders are from PICA for the lower component of the AVM and superior cerebellar artery or SCA as expected for the vermian AVM. This patient underwent surgery in the lateral position suboccipital craniotomy. You can see the transfer sinus the dura has been tacked up here C1 and area for him in Magnum right cerebellar hemisphere left cerebellar hemisphere. Let's go ahead and identify the components using a Flathead hundred and ICG angiography. You see the training vein, very evident and also, and the draining vein over the cerebellum. Here's the Floyd hundred, illustrating the draining vein going into the straight sinus and also another smaller component of the malformation as expected along the posterior inferior aspect of the operative field. This is a nice view again, localizing the malformation especially the more inferior one which is smaller and can be missed on initial inspection. I went ahead and started resection of the smaller malformation which turned out to be relatively bloody. In fact, you can see entering the cerebellum and circumferentially disconnecting the malformation. I try to preserve as much as cerebellum as possible. Initially got into part of the nitus but continued to coagulate the feeding vessels to the malformation and ultimately circumferentially disconnect the nitus. You can see via abnormal vasculature the nitus of the malformation. I'll go ahead and coagulate the feeding vessels and the natus. It appears at the same time until they're relatively normal. Cerebellum is encountered. Here you can see the nidus being coagulated it's a relatively small malformation. Therefore one does not have to stick with the principle of disconnecting the feeders before removing the natus. Looks like we're almost done with this one. Again inspecting the resection cavity to make sure that the malformation is completely removed. Am disconnecting the draining vein again, inspecting the cavity very carefully and redirecting my attention toward the larger malformation along the superior venous. And one last time securing hemostasis making sure no further bleeding is noted. The draining vein for this smaller malformation was therefore disconnected since this malformation was already removed. So I can retract the cerebellum more inferiorally and mobilize it more inferiorally so that the superior vermin malformation is easily visible. And I can reach the deeper feeding arteries to this malformation from the superior cerebellar artery. If I had not taken that draining vein it would have been difficult for me to reach deep towards the edge of the tentorium in order to disconnect the feeding arteries to the malformation. Therefore, this was an important strategy during resection of this malformation. As you can see I'm focusing most of my attention on disconnecting the feeding arteries that were some bleeding from the tentorium venous bleeding that I usually use from a soak gel foam and pack their bleeding point. Coagulating the bleeding point unfortunately enlarges the site of the bleeding and can actually lead to more aggressive bleeding. Here is again, going around the malformation and disconnecting it as much possible. You can see that I really attempt to disconnect the SCA branches very early on so that the malformation is devascularized. As we continue devascularizing further we'll see some deflation of the natus and decrease in the turgor of the natus. Here you can see some of the very apparent feeding vessels within the pier from the superior cerebellar artery. This one is very apparent. Again, the drain in vein is carefully protected significant traction on the vein is also avoided. After the feeding vessels are disconnected it's relatively easy to remove the natus with relatively minimal bleeding. Here, again, finding the feeding vessels from the SCA. This one is a big one. It's been disconnected. This appears to be the draining vein. Obviously we wanna protect that carefully until the malformation is circumferentially disconnected. Here's the more superficial part of the malformation this being also dissected using sharp section staying close to the natus but not too close. And again, moving around their natus and disconnecting it from the surrounding cerebellum. We're reaching the more inferior aspect of the malformation. Maintaining hemostasis along the pier planes here is again the draining vein. Disconnecting the malformation now more inferiorally and reaching toward the anterior plane. The deep white matter feeders of their cerebellar malformations can be quite vigorous even compared to their super tentorial counterparts. Here's a deep white matter feeder. Again, staying on the cerebellar side so I can find some normal section of the deep white matter feeder that is coagulable. Seems like we're almost done with the inferior part of the malformation. Relatively normal cerebellum is apparent before we go elsewhere I'll go ahead and obtain hemostasis. Now that most of the malformation is disconnected I'll go ahead and tackle the draining vein. Again you want to just disconnect the draining vein and not inadvertently affect the vein of Galen here. So am bleeding from the vein that will be controlled in a moment. Can you wanna maintain the patency of the vein of Galen that you can see here? So again, this is another important point in this video to differentiate the identity of the vein of Galen versus the draining vein and do not inadvertently effect the patency of the vein of Galen. The natus is now removed. Of course hemostasis is very carefully obtained. All the pier edges are coagulated also inspected for absence of any residual malformation. Here's the final product. And the postoperative angiogram demonstrated adequate resection of both malformations without any evidence of AV shunting and the postoperative CT demonstrated Northernness ischemia. And this patient made an excellent recovery from the surgery. Thank you.

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