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Large Posterior Lateral Frontal AVM: Efficient Resection Techniques

July 29, 2016


Here is another video discussing resection of a large complex posterior lateral frontal Arteriovenous malformation. This video also reviews management of deep white matter feeders. This is a 52 year old female who presented with acute Intracerebral hemorrhage. CT Angiogram demonstrates the malformation located in the posterior frontal lobe just behind the area of the hematoma. There is a number of large draining veins related to this malformation. The MRI also localizes the tumor relative to the sensory motor cortex just behind the malformation. In expectation of her surgery, an arteriogram was completed. You can see a very dominant distal ACA branch feeding the malformation. The later phases of the angiogram of the lateral view of the carotid injection further demonstrate the angio architecture of the malformation and a large draining Parasagittal veins. Here is an AP view of the angiogram. Again, the carotid injection, you can see that single dominant ACA feeding vessel to the malformation, large dominant draining veins on the surface joining the superior sagittal sinus. Importantly, one can see these multiple dominant deep white matter feeders from their lenticulostriate arteries. These deep white matter feeders can be quite problematic. And therefore, the surgeon has to be prepared at the time of managing these dominant deep white matter feeders. Here's the incision, sizable one. Before I start dissection of the vessels, I wanted to better understand the surface angio architecture of this AVM. Here again, is a Parasagittal craniotomy. Superior sagittal sinus is located here, the surface anatomy. Here is a early phase of the ICG angiogram, noting that these are the feeding arteries, and this is a large draining vein. Here is another one here. Looking at the surface of the brain, Some of the very dominant and high flow arterialized veins can look very similar to feeding arteries. Therefore, this is unquestionably a feeding artery. This one is a feeding artery, and this is the large draining vein. I can see other veins joining each other in this location. This vein joins the superior sagittal sinus. I started with circumferential peel disconnection of the malformation. The hemorrhage was located anteriorly. Therefore, the initial cortical incision exposed the hematoma and decompressed it. Next, I disconnected these cortical feeding vessels as demonstrated on the ICG angiogram. Here's the mural medial disconnection of the malformation. One of the distal ACA branches was also found and disconnected . Additional removal, a clot would decompress the brain and allow more flexible angles in mobilizing the AVM. I expect the dominant deep white matter feeders just to be located about here, underneath the AVM. There should be plenty of clot, just inferior to the AVM. Here's the draining vein. The thick arachnoid bands are opened. This maneuver is very important, because later I'll find a sizeable feeding vessel to the malformation just next to the vein. I continue to work around the veins, while disconnecting the AVM from the arterial feeders. Here's a nidus of the malformation, clearly evident, Further clot was removed just along the lateral inferior aspect of the malformation. Some of these subcortical feeding vessels to the malformation were also disconnected. Continuing to work between and underneath the veins. Here is one, here's another. Now dissecting just on the side of the dominant vein. This is an important principle, because very frequently there is a very sizeable feeding artery next to the vein that can keep the vein arterialized despite complete disconnection on the nidus. Here's that very sizable arterial vessel. It was coagulated and sacrificed. Here's another one, coming in a little bit more laterally. The veins appear more collapsed. You're now working just along the posterior inferior aspect of the malformation. Here's the nidus. You can see these working channels or windows between the veins. Here's more, anteriorly. I'm getting close to those lenticulostriate deep white matter feeders. Their control can be quite difficult. If they're not coagulable, I remove a small amount of white matter around them. So a segment of them slightly distal to the nidus is identified. This more proximal segment away from the nidus can be more coagulable due to more robust walls. And continuing to work around those lenticulostriate feeding vessels and coagulating them. Here's a de magnified view of our operative corridor. Neuronavigation was used, as well as a CT angiogram, to make sure I stay outside the nidus. Some of those deep white matter feeders are now coagulated. Now coming more along the posterior border of the malformation and working underneath it. Here are some of the other deep white matter feeders, this time along the posterior border of the malformation. Again, removing small amount of brain and securing a portion of the vessel away from the nidus is the best operative maneuver to find a portion of the deep white matter feeder that's coagulable. Packing is not advised as it may lead to remote inter cerebral hemorrhages. Here's another view. Let's go ahead and do an ICG since most of the veins are decompressed. Here you can see most of the veins are very minimally filling, specially the most dominant one joining the superior sagittal sinus. This vein appears to be more functional. I went ahead and disconnected the mural medial vein so that the malformation can be mobilized and its final connections at its apex are disconnected. You can see that the disconnection of the parasaggital vein untethered the nidus allowing it to be rolled more laterally. Therefore, I can have a more flexible operative angle toward the deep white matter feeders that have been quite concerning. You can see some of these lenticulostriate deep white matter feeders. Again, removing slight amount of brain so we can get a segment of the vessel slightly away from the nidus that is more coagulable. You can see these problematic white matter feeders again. During the final stages of dissection, the operative feed often appears more bloody. Hemostasis is only achieved if the AVM is efficiently extracted. Here's mobilization of the AVM out of our operative field. The final connections based on the draining veins are also sacrificed so that the nidus can be removed. Here is another vein. Couple of deeper vessels that are coagulated and cut. It's a very sizeable AVM. This portion of the nidus is also being delivered. This lobule was encroaching upon the posterior edge of the brain. Final result after hemostasis was secured. Brain is very relaxed. Postoperative angiogram revealed complete removal of the malformation without any evidence of shunting. This patient's Hemiparesis improved significantly during the postoperative period. And actually, she was neurologically normal at the one month follow-up. Thank you.

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