July 06, 2015
Let's go ahead and review this video, which involves management of a Premotor terracotta malformation. The focus of the video will be how to manage the daunting deep white matter feeders. This is a 46 year old female who presented with seizures. MRI evaluation demonstrated location of this poster funnel cortical artemis malformation. The central sulcus is located here. This AVM is essentially abutting the motor cortex. Here's a sagittal image with extents of the deep white matter into filtration. As expected most of the feeding muscles originated from the middle cerebral artery and the draining veins joined the superior sagittal sinus. One may question the safety of microsurgery for such an AVM. And I may not be able to argue against them in that regard. None of us especially underwent an exploratory surgery prior to the operative intervention. She only went aggressive embolization of her malformation. You can see the deep, white matter feeders originating from the MCA. These white matter feeders are quite daunting, and I do believe this important preoperative findings. In other words, such long lenticular, straight arteries feeding the apex of the malformation so deep within the white matter, these findings are most likely a contra-indication for operative intervention. When the malformation is so close, to the functional cortices. Nonetheless, this patient underwent a posterior for craniotomy. You can see the superior sagittal sinus, the draining veins joining the sinus. I obtained an intraoperative ICG angiogram initially to better characterize the architecture of the malformation. Obviously deep draining veins, or any other draining may superficially has to be protected, during the initial parts of the operation. Let's go ahead and inject the ICG. Here you can see the nidus of the malformation reaching the cortex as well as some of the deep draining veins that are joining the superior sagittal sinus. Here's another view and run of the ICG. Or some cortical small pedicle vessels joining the nidus. From the time I started white matter dissection, I continuously ran into bleeding. I believe part of the reason for bleeding was that because the functional cortex was so close. I attempted to maintain my dissection to close to the nidus of the malformation, and occasionally actually dissected, slightly into the nidus. Although all the drain veins were carefully protected. I continued to disconnect the malformation. Some of the deep white matter feeders were protected or controlled using first methods to dissect them and isolate them and then place it. I'm sorry, an AVM clip around them. Here you can see some bleeding from a very robust, deep white matter feeder. The deep white matter feeder essentially pointing at us. Should be relatively accessible. I can see the bipolar forceps are essentially non-effective. Since this vessel lacks a robust wall. In this situation it's best to remove small amount of white matter around the vessel and pursuit of a vessel slightly away from the nidus, so that the more normal wall of the vessel can be secured and coagulated. I failed to perform this technique. I continued to coagulate the vessel without following it and pursuing it into the white matter. Therefore bleeding continued. Often, some bleeding is seen in the operative field, but the vessel may retract and actually lead to intracerebral hemorrhage slightly away from the area of the operation. One reason I did not pursue this vessel was the location of the functional cortex just behind the nidus. I was trying to protect of the normal brain as possible. My next maneuver involved placement of an AVM clip. I have found these clips relatively not helpful. As you can see here it did not make a difference. This clip was subsequently removed. It's often difficult to remove this clip because it's so stiff. That's why I usually use the aneurysm permanent clips, the small ones in place of the AVM clips. Here's a final attempt at removing this clip. It can be a propered maneuver, should have involved isolating this large deep, white matter feeder. Slightly away from the nidus securing, a relatively normal segment of it. This white matter of feeder retracted. You can see some tear within the cortex, nearby the malformation indicating the occurrence of an intra-cerebral hemorrhage. Some brain swelling is also evident. If the deep white matter feeder was handled appropriately, this could have been avoided. Now I have to create additional courticonomy and follow the hemorrhage and be able to find the actively bleeding deep white matter feeder. So it can be quite coagulated and controlled. Small part of the normal white matter had to be removed. So visualization of the source of hemorrhage is possible. Honestly, this is far from an ideal situation. The deep white matter was secured slightly away from the nidus. Weight was controlled using bipolar coagulation. At this junction, I aborted the operation. I felt the risk of removing the nidus it's too great. My primary goal at this stage is securing hemostasis. Foreclosure, post operative CT scan demonstrated a sizeable hematoma. Postoperative angiogram demonstrate a small amount of residual artemis malformation. The patients suffered from haemor paralysis however made a reasonable recovery six months after the surgery. This operation essentially downgraded this malformation so that it is amenable to radiosurgery. This patient subsequently underwent radio surgical treatment of her residual malformation. Which led to a complete cure without any residual Av shunting on an angiogram three years after the surgery. You can see some encephalomalacia at the area of the surgery. One year after the surgery, she was left with slight amount of haemor paralysis and this was noted not to be disabling. Thank you.
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