Peri-atrial and splenial arteriovenous malformations can be more diffused than expected on preoperative angiogram. This is a 41 year-old female who presented with migraines. MRI evaluation revealed an incidental small right-sided splenial, pre atrial malformation. The lateral ICA injection demonstrates this relatively diffuse malformation somewhat bi-lobed associated with a draining vein over the splenium going around the splenium and draining into the deep diencephalic veins. The AP view of the carotid injection further illustrates the diffuse nature of the malformation associated with this medial splenium draining vein. Patient underwent a resection using the interhemispheric approach. Patient is in the lateral position with the right hemisphere in the dependent position. So that gravity with traction is utilized. A lumbar drain was also installed. Here's the final patient positioning using CSF drainage via the lumbar drain and gravity retraction. You can see the right hemisphere has been mobilized effectively away from the fox. No fixed retraction is necessary. Here's the dominant arterialized draining vein over the splenium. The hemisphere dissection continues and more lateral operative trajectories necessary, to be able to expose the nidus and the diffuse white matter feeders in this case. There is a couple of potentially corkscrew vessels. You can see also something that resembles a nidus more laterally on the splenium and tore the pre-atrium. There is corkscrew vessels were coagulated and cut. The principal intraoperative findings included really these deep white matter feeders without a bonafide AVM nidus. I continue to fight through these white matter feeders within the splenium and control their bleeding. The best method to control bleeding from these white matter feeders is pursue them further away from the AVM nidus where their valves are more robust and more amenable to a bipolar coagulation. Here's another small piece of nidus that was removed. Anything that appeared somewhat abnormal and hypervascular was evacuated until the atrium was entered, it's choroid plexus. Obviously exposure of the atrium at the end of resection of the AVM is mandatory to confirm complete exclusion of the malformation. Again, choroid plexus in a tumor or any clot within the Atrium was evacuated. Here's that draining vein. I inspected it surroundings, make sure there is no hidden arterial feeding branch next to the vein. As the vein appear darker, I ultimately sacrificed the vein as well. Here's the coagulation of the vein and it's disconnection. I felt comfortable that most likely the AVM is now excluded. However, an intraoperative angiogram demonstrated some residual malformation. I placed an aneurysm clip within my resection cavity to be able to localize the residual malformation in relationship to the cavity of resection. You can see that the residual AVM is just below the clip and maybe slightly interior. Let's go ahead and further inspect or resection cavity. I suspected that there are some residual diffused white matter feeders that were not handled, during the initial phase of the operation. Again intraoperative angiogram is quite useful for these diffuse AVMs, since it's not clear where the boundaries of the AVM nidus end. Here you can see further deep white matter of feeders that I encountered and controlled. Moving more posteriorly, you can see a leech of, white matter feeders that are being coagulated.. Here is the clip that was placed for intraoperative angiogram, further inspection of the cavity this time, again does not demonstrate any residual malformation Hemostasis secured post-operative angiogram revealed complete exclusion of the malformation, both on the lateral carotid as well as APA carotid injections. There is no evidence of Avi shunting, postoperative CT scan revealed no silent complicating features, and this patient made an excellent recovery. Thank you.
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