May 05, 2015
This nice video reviews techniques for resection of a paramedian occipital arteriovenous malformation. This is a 12 year old girl who presented with multiple seizures. MRI evaluation demonstrated as sizable occipital paramedian arteriovenous malformation, angiogram as expected detailed the feeding vessels primarily from the, this full branches of the posterior cerebral arteries, the draining veins were numerous. Some of which were cortical. Some of which drain to the superior sagittal sinus. Patient was taken to the operating room placed in the latter position. A lumbar drain was installed to allow early brain relaxation. You can see the generous scalp incision craniotomy was completed in the portion of the superior sagittal sinus and the transfer sinus was unroofed and the arteriovenous malformation was uncovered. You can see the art realized veins or the cortex. The draining veins were carefully isolated and protected during the early stages of the operation. Next, I continue to circumferentially disconnect the malformation from the surrounding normal cortex. Again each one of the remaining draining veins were protected as much as possible. Here you can see a very reasonable isolation of the nidus. All the draining veins have been primarily left intact. Some of the draining appear darker. I continue to disconnect, the medial and inferior peel surfaces of the malformation. Here's the tentorium falx cerebelli and their junction. Most of the malformation is now disconnected, except that the disproportion of the malformation, some of the darker draining veins were sacrificed so that the malformation can be mobilized out of the resection cavity and the deeper portion of the nidus accessed. Now the malformation is gently elevated the deeper or apex portion of the malformation reached and disconnected. This AVM was rather void of robust, deep, white matter feeders. And therefore it was relatively easy to resect and disconnect the deeper proportion of the nidus. Here you can see the bottom section of the nidus that has been disconnected and transected from the white matter. Here's the magnified view of the operative corder. Finally the last and most dominant draining vein is coagulated and cut. You can see falx and the junction with the tentorium. No significant bleeding is encountered. Here's another smaller draining vein that is very dark and will be disconnected. The resection cavity is carefully inspected, no obvious malformation or residual nidus is apparent. Immaculate hemostasis is secured. In this case, an intraoperative angiogram was performed, which revealed gross total resection of the malformation subsequently a post operative angiogram also confirmed complete removal of the nidus without any evidence of even minor AV shunting, three months MRI revealed the expected findings related to resection of the malformation. Thank you.
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