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Peri-atrial AVM: Transfalcine Approach

January 15, 2016


This is another video in a series of transfalcine procedures for resection of an anterior peri-atrial arteriovenous malformation. This is a 44 year old female who previously underwent radio surgical treatment of her malformation, after embolization. This AVM is primarily peri-atrial and also coming close to the area of the central labial. The AVM did not obliterate after three years. Following hariel surgical treatment. You can see the location of the malformation primarily off midline. Slightly more anterior than the usual Peri-atrial lesions. The AVM owns a very small nidus associated with a small draining vein. The embolization material can act as a reliable navigation tool doing resection of the malformation. So, the transfalcine approach through a contralateral interhemispheric corridor provides a cross-court trajectory. To reach the lateral pole of the lesion of heeding the need for aggressive ipsilateral hemispheric retraction. Essentially the posterior transfalcine transprecuneus approach is founded on the concept of using the contralateral operative trajectory to argument, a more tangential working angle to the more difficult to reach lateral surgical target through a midline route. This approach emphasizes the importance of operative work in angles versus necessary operative space through less disruptive exposures as a more viable parameter. To achieve desirable results. Let's go ahead and illustrate these concepts and unfold, the findings during the surgery. You can see the patient is placed in the lateral position. The head is somewhat parallel at the level of their sagittal suture to the surface of the floor. A lumbar drain is used for brain decompression. The incision crosses the midline. So, that the superior sagittal sinus is unroofed. Here's the angle of the head against the surface. And the angle of the neck against the surface of the floor. The craniotomy crosses the midline so that the super sized sinus can be mobilized. You can see the two sutures along the superior falx mobilizing the dura sinus. Obviously this is the normal unaffected hemisphere. Intraoperative navigation guides, the location of the incisions within the falx. The first incision is relatively parallel to the access of the superior sagittal sinus. The second incision is perpendicular to the first one and extends all the way to the inferior sagittal sinus. The embolization material is readily apparent on the contralateral medial hemisphere. Two sutures are placed over carotenoid paddies. To mobilize the hemisphere. Here you can see the embolization material within the pedicles of the malformation Correlating the location of the embolization material to the preoperative imaging assists with intraoperative guidance. Here, you can see it in some of the embolization material. I continued to circumferentially disconnect the malformation and the embolization material as much as possible. And ultimately disconnect the arterialized vein. As evident here slightly more posteriorly. And this is anterior. This is posterior. Some of the theaters were disconnected from the anterior circulation. Here's the gliotic peri-AVM area. Complete removal of the embolization material is not necessary. The incision within the falx is extended more posterially. To ensure complete exposure of the lesion. Although the embolization material within the pedicles to the AVM are now removed. The embolization material within the nidus are preferably removed to avoid the risk of future recanalization of nidus and AVM recurrence. Parts of the AVM can be quite fibrous. The AVM is again, circumferentially disconnected. From the surrounding normal cortex. You can see the radiation changes within the pedicles from the PCA. The gliotic areas around the AVM are identified. Some of the partially embolized pedicles are disconnected. The AVM is almost completely disconnected at this stage. You can see removal of the AVM. Through this small operative corridor. The posterior body of the lateral ventricle, as well as the area of the trigone. Are found choroid plexus was also apparent. There is no residual malformation present. Here's the final operative corridor. This is the postoperative angiogram. Which demonstrates gross total resection of the malformation without any early draining vein. Thank you.

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