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Paramedian Frontal AVM

July 29, 2016


This video illustrates resection of a Paramedian interior frontal Arteriovenous Malformation and more importantly emphasizes the critical importance of surgeon's perseverance in order to disconnect all the feeding vessels early on to avoid bleeding during the later stages of the operation. This is a 23 year old female with intractable headaches. MRI evaluation revealed a primarily interior perimedian arteriovenous malformation relatively sizeable. And an angiogram also confirms their feeding vessels, both from the ACA as well as the MCA feeding the malformation. I expect to have some deep white matter bleeding that can be difficult to control, especially from the lateral aspect of the malformation. Missional underwent through section via a left sided parasagittal craniotomy. You can see the draining veins joining the superior sagittal sinus. This small vein that appeared not to be arterialised was disconnected early on. The dominant parasagittal draining vein was untethered but protected. My goal is to reach the interhemispheric fissure and disconnect the ACA feeding ranches early on. Here's another dominant drainig vain joining the sinus. Here's the interior skull base. Here's another draining vein joining the inferior sagittal sinus. I used flow 800 study of their vessels to, again, more clearly identify the early feeding arteries. You can see the draining vein, the feeding vessels, a color map of the floor 800 module further illustrated the feeding vessels both from the MCA in this case and those hidden within the interhemispheric fissure. I entered the interhemispheric space. Clearly identifying the vessels that were directly feeding the malformation. Transitional or emphisage vessels were protected. I should have persevered more and disconnected all the feeding vessels in this case to provide more control over the feeding system of the nidus. However I did not. And you will see in the later stages of the operation I ended up facing some torrential bleeding. Here's again further interhemispheric dissection more anteriorly. Some bleeding was encountered here from a feeding artery within the interhemispheric space. This point of bleeding was clearly identified and controlled. Here are some other feeding vessels that were not aggressively controlled early on. Here you can see the malformation. Another feeding vessel was disconnected. I wasn't sure if this is a transitional or emphasage vessels or a feeding artery. Here was some bleeding from a feeding vessel. Very closely related to the dominant vein here. This is not an unusual finding. One has to protect the vein during such bleeding episodes. Next I circumferentially disconnected the malformation from the distal MCA branches. Sting just outside the nidus. Again looking into the interhemispheric fissure. Continuing along the posterior margin of the malformation. Avoiding the nidus. Maintaining the dissection plane within the white matter. Here you can see the nidus. Another nice view of the nidus and the surrounding white matter. Floor of the inter fossa. Peel feeding vessels are coagulated and cut. Mobilizing the malformation more medially to protect as much of the normal white matter as possible. During circumferential dissection of the malformation. In working just underneath the AVM. Here is more posteriorly. I encountered some white matter bleeding. Some of the deep white matter feeders that were noted on the preoperative angiogram were carefully coagulated and cut. However their control can be quite challenging. And the farther you get from the nidus the more likely you'll find relatively normal wall for these vessels. Tnese relatively normal walls can be an opportunity to control these white matter feeders. You can see the draining veins are darker now. That means that our circumferential disconnection has been effective. Can see the draining vein is quite dark. Here is further disconnection of the ACA branches in a more sub peel and controlled fashion. You can see that I'm maintaining my dissection just on the periphery of the malformation to assure that any emphisage vessel is carefully protected. Here's another large arterial feeder to the malformation. I continue to dissect around this complex to make sure any emphisage vessel is protected. Ultimately this dominant feeding vessel was coagulated and cut. Clips were used for their control before the vessel was coagulated and cut. Again you can see this transitional or emphisage vessel is protected. Here's again working lateral and inferior to the malformation. The problematic deep white matter feeders continue to haunt us. Here's working along the anterior cranial base. The anterior draining vein was temporarily occluded. The malformation appeared relaxed during this occlusion and therefore the vein was sacrificed. Malformation was removed and as you can see the best method of hemostasis is to remove the malformation. No arterialised vein is apparent. Postoperative angiogram demonstrated complete exclusion of the malformation. This patient made an excellent recovery. Thank you.

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