Insular Cavernous Malformation

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This video reviews, the basic principles for a section of super tentorial cavernous malformations, and more specifically within the dominant insula. This is a 25 year old male who presented with progressive hemiparesis related to this large recurrent cavernous malformation within the dominant insula. This lesion extended into the area of their corona radiata. He subsequently underwent a left frontotemporal craniotomy the dura over the frontal lobe temporal lobe to over the fissure. I initially cut the dura just parallel to the fissure so I can assist them on a scarring within the subdural space. Since scoring can be an issue in terms of dissecting and opening the dura. If significant scarring was present, I would have limited my dura exposure, just superficial to the fissure. Now the fissure is split using the inside to outside technique. The cavernoma that involves the insula is immediately visible. The posterier aspect of the fissure also split so that I can have, a generous access to the entire length of the malformation. Now the surface of the malformation is entered. A piece of the lateral wall of insulin is removed the internal contents of the malformation, including the prod products are evacuated. Here you can see part of the clot in different stages of development. Also parts of the malformation from inside to outside are evacuated. Some of the feeding arteries to the cavernous malfunction are quite regulated and cut. Next I try to develop a dissection plane along the periphery of the malformation against the glottic perilesional brain. Maintaining this dissection plan can be challenging at times. One has to be very careful of the two branches that are located along the more inferior and lateral aspect of the malformation. Here's is developmental venous abnormality that obviously has to be preserved during our resection process. Here's the glottic margin around the malformation. Again the malformation is now removed piecemeal. So more spaces available for the dissection of the adherent more medial wall of the malformation. Here's another piece that was evacuated. Again the development venous abnormality is protected during our resection. One has to be careful to differentiate between the glottic margin and the malformation that can be discolored similar to the glottic margin you can see the difference here very clearly to avoid further recurrence of this malformation obviously all the cavernous malformation remnants should be removed. I'm now cleaning their resection bed. You can see the small lenticular straight arteries at the bottom of my resection cavity. Obviously all these perforating vessels have to be carefully protected, small minor residual feeding vessels to the malformation or further coagulated. I'm relatively satisfied with the extent of resection at this juncture. And another developmental venous abnormality, you can clearly see the glottic margin of our resection cavity. Here's a perforating branch, a lateral lenticular steroid artery aggressive coagulation's should be avoided to prevent any injury to these perforating vessels. Ample amount of irrigation is used to clear the operative field and the post operative MRI demonstrated reasonable resection of this tumor. The patient did not suffer from any new neurological deficits. Thank you.

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