Medial Atrial AVM-Transfalcine Approach

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This is another video describing the utilization of the Transfalcine Approach for arteriovenous malformations residing on the medial wall of the atrium or the trigone. This is a 26 year old male who presented with a sudden onset headache and spontaneous intracranial hemorrhage along the medial wall of the atrium. You can see some of the flow voids consistent with the diagnosis of an arteriovenous malformation. Cerebral angiography confirms the presence of the malformation. The feeding vessels originate from the PCA, as well as the distal ACA, and MCA branches. The draining veins are primarily along the medial parietal lobe draining into the superior sagittal sinus, as you can see. The large feeding vessels entering the intra-inferior aspect of the arteriovenous malformation. I approached this tumor via the Transfalcine Approach, placing the normal hemisphere down. You can see the superior sagittal sinus, the dura is reflected. Two sutures are placed along the superior aspect of the falx. A suture mobilize the superior sagittal sinus. A T-shaped incision is created within the falx, so that the AVM can be exposed tangentially through the Transfalcine Approach. A lumbar drain is used for early brain decompression. Here's the T-shaped incision within the falx. Obviously, the draining vein has to be carefully protected. You can see the surface of the malformation. The falxine incision is extended interiorly and posterially. The falxine flaps are mobilized. The hemorrhagic surface of the medial lobe is apparent. Here's the second falxine flap that is being mobilized. Pieces of Telfa are used to protect the brain. You can see the draining vein traveling along the medial hemisphere. Intraoperative ICG angiography was next conducted to study the angio-architecture of the malformation before tackling it. This modality can assist with identification of early arteries and draining veins, as you can see the draining vein localized here. Here, again, is another view of the ICG, and the finding slightly more posteriorly. The AVM is then circumferentially dissected. The feeding vessels are disconnected. The draining vein is preserved until the malformation is completely delineated from the surrounding cortex. The gliotic margin of the malformation is identified. I expect to enter the temporal horn at some point during dissection of the medial capsule. Here's the clot from the malformation. The draining vein was subsequently disconnected, the hematoma cavity was cleaned out, and the temporal horn is subsequently entered. Here is the choroid plexus at the tip of the suction device. Here is the magnified view of the operative cavity through the Transfalcine Approach using retention sutures both on the falx, just below the superior satchel sinus, and also on the two falxine flaps, leading to the contralateral atrium and its corresponding choroid plexus. This approach offers early control over the medial hemispheric feeding vessels, and also preserves the draining vein via its early exposure. The closure is conducted in standard fashion. This patient recovered from his surgery uneventfully. Thank you.

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