March 03, 2015
This video reviews the events surrounding hemorrhage from an occipital interhemispheric arteriovenous malformation This is an 18-year-old male who was found down and was diagnosed with a large left-sided acute subdural hematoma. Due to his neurological status, he underwent an emergent evacuation of the subdural hematoma. You can see that the hematoma tracked into the interhemispheric space medial to the occipital lobe on the left side. He made an excellent recovery from his hematoma evacuation. A post-surgical angiogram demonstrated a small occipital arteriovenous malformation associated with a draining vein. This AVM was recognized as the cause of his acute subdural hematoma. I have seen at least two other cases where a small interhemispheric occipital hematoma, has led to an acute convexity subdural hematoma related to a small arteriovenous malformation. After recovery from his subdural hematoma evacuation, he underwent a parasagittal occipital craniotomy. Patient is in the latter position, here's the midline, here's the left side, trochlear would be located here and the transfer sinus would be here, superior sagittal sinus was unroofed and the occipital interhemispheric space was accessed. The interhemispheric space was entered. I searched for the draining vein leading to this superior sagittal sinus. Here's the interhemispheric coder. Microdissection revealed, some calcifications in this area, which I did not feel would be related to the malformation. In this case, I was looking for they're feeding pedicles to the malformation, here you can see some of the veins entering into the superior sagittal sinus, but most likely not related to the malformation. This draining vein appears normal and relatively dark. I continue dissection more superiorly. Here's a vessel entering the cortex in this area, feeding vessel should be from one of the distal branches of the PCA. Here's the dissection around this area of the interhemispheric space. I believe the AVM is essentially located here, Other vessels were found most likely emphasized. The AVM is again here. Here's one of the distal branches of the PCA, here's the vessel entering the AVM. I felt that this is most likely the feeding artery toward the malformation. Most likely this is a draining vein on the cortex. Here's the malformation, fed by the distal branch of the PCA. You can see the artery turns around and enters the malformation. I circumferentially disconnected the part of the cortex, affected by the malformation. Here's the draining vein that's partially arterialized. None of the feeding vessels were sacrificed, until their identity was carefully inspected to assure that none of the branches are emphasized vessels. Peel disconnection of the border of the malformation is accomplished. The AVM is disconnected from the underlying white matter and subsequently disconnected. This part of the cortex appeared engorged and somewhat attempting this, the draining vein was coagulated since it still appeared arterialized despite removal of the malformation, I felt that small residual piece of malformation can be present . I'll place the temporary clip on this potentially draining vein and no change in the malformation occurred. Therefore, small residual malformation at the bed of the resection cavity was suspected. As you can see, there is some abnormal white matter feeders in this part of the posterior occipital lobe. This part of the affected brain was also removed. Here you can see a feeding vessel to the malformation, that's being controlled. It's best again, to preserve all the important emphasized vessels to ensure any compromise of their visual cortex. The bipolars were prepared for control of this single vessel to the malformation. As you can see, I remain patient and find the exact site of the bleeding to ensure that the adjacent vessel is not affected by aggressive bipolar coagulation. Set of non-stick bipolars can be quite helpful in this situation. Ultimately, this vessel was controlled. Here's the interhemispheric quarter. I don't see any other abnormality at the level of the cortex. The resection cavity appears very clean. A feeding vessel has been disconnected, no other arterialized pain over the cortex was visible. Here you can see the draining vein that appear darker at the end of our resection. Postoperative angiogram, confirmed exclusion of the malformation, no evidence of AV shunting and the three months MRI revealed the expected postoperative changes and this patient's vision remained stable after his AVM surgery. Thank you.
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