This video reviews, the techniques for resection of a small Ruptured Occipital Arteriovenous Malformation, and also demonstrates the techniques for performance of a Parasagittal Occipital Craniotomy. This is a 30 year old female who presented with sudden onset of headache and Occipital Inter Cerebral hemorrhage. You can see the location of the hemorrhage on the CT scan. A catheter angiogram was also performed, which demonstrated a Small Occipital Arteriovenous malformation fed primarily by the distal branches of the PCA. This malformation on the small draining vein toward the superiorior Sagittal sinus. She subsequently underwent a left Parasagittal Occipital Craniotomy for evacuation of the hematoma and resection of the malformation. You can see placement of the patient on, on the operating room table. In the lateral position, her head was fixed in the Mayfield pinion. The head was turned toward the floor. The midline is marked at the edge of the head shave. And the incision as you can see is para-midline line, centered over the area of the hematoma. Neuro navigation was used for mapping of the incision. The details of the incision and the craniotomy are reviewed here, following performance of incision, Cranium clips are applied, the peri-cranium is stripped away and self-retaining cerebellar retractors are positioned in place. Here's the sagittal suture or the superior-satchel sinus two bur-holes are placed just lateral to the sagittal suture. Navigation again confirms the exact location of the superior sagittal sinus. Again, this is the left side. This is the midline , two burholes are placed just over the sinus Gel foam powder soaked and thrombin is used for achieving hemostasis through the burholes, generous burrholes are created, so I can see clearly the extent of dural exposure within the burrholes to avoid any injury to the Venus sinus. A relatively small Parasagittal Craniotomy is quite effective here since the hematoma, which is very close to the area of the interim aspheric space. The last bony cut is performed over the venus sinus. So if any venous injury is encountered the bone flap can be elevated on a timely fashion. The drill is kept perpendicular to the surface of the skull at all times. You can see the a small extent of Paramita midline exposure. Epidural hemostasis is accomplished. The dura is open and curling in fashion centered or based over the area of their superior satchel sinus. Dental tool may be used to extend the dural incision. So an injury to the underlying cortex is avoided Following the exposure of the cortex that dura is retracted using retention sutures and neuro navigation is used to complete a corticotomy just over the area of the hematoma that is closest to the surface of the cortex. Here's the initial corticonomy, just over the most superficial part of the hematoma. The corticotomy extended to the level of the hematoma after which the hematoma is thoroughly evacuated and the hematoma cavity, the walls of which are inspected for any evidence of a malformation. Here's the peaceful removal of the hematoma using pituitary Rongeurs. Though to the corticotomy is kept as small as possible. The patient did have a hemonomous before surgery. The more superior aspect of the hematoma cavity does not demonstrate any evidence of abnormality. However, the inferior aspect appears to have some abnormal tangled vessels that are most likely evidence of the malformation. And these vessels are coagulated as there was some bleeding noted in this area. The tentorium is breached. Further inspection reveals, no obvious vascular abnormality. The dura is closed. The bone flap is replaced. I do not persist on a watertight dura closure for supratentoral craniotomies. However, in the posterior fossa, I do believe a watertight door closure is necessary. Postoperative angiogram demonstrates complete excision of the malformation without any further AV shunting. Thank you.
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