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Peri-Atrial AVM: Transfalcine Approach

August 17, 2016


Let's review another case of a peri-atrial AVM and its reception via the transfalcine approach. This is a 10 year old boy who presented with ICH and IVH. You can see the distribution of the blood within the brain on this actual CT scan. The CT angiogram demonstrates the location of the malformation just lateral to the clot as well as superior and is slightly anterior on his sagittal image. Preoperative cerebral arteriogram was completed. As expected the malformation is fed by their posterior cerebral artery branches and the drainage system leads to the dying cephalic veins. The AVM is relatively large and extends all the way to the level of the atrium. Again, as expected. This patient underwent resection in the lateral position, using the transfalcine approach. The AVM is on the left side. The right side was placed in the dependent position so that gravity retraction can mobilize their normal hemisphere and the transfalcine approach used to reach the affected hemisphere. A lumbar drain was also inserted. You can see that the head is turned toward the floor about 45 degrees. Here's the location of the head in relationship to the body. Following completion of our parasagittal craniotomy, you can see the superior sagittal sinus was ungrooved, the dura was incised based over the sinus. And I like to use two sutures within the superior aspect of the falx to mobilize the sinus out of my operative corridor. A T-shaped incision was created within the falx. You can see the vertical incision extended all the way to the inferior sagittal sinus. The vertical incision is completed until the corpus callosum is encountered. Corpus callosum just underneath the suction. Here you can see that the T-shape incision is complete all the way to the level of the corpus callosum. Here's the horizontal portion of incision within the falx. Here's the gliotic margins around the AVM. Two sutures are used to mobilize the leaflets of the falx out of our operative corridor. Here's the arteriovenous malformation. Neuro navigation is used. The draining vein is anterior to the malformation. The vein is protected and neither is circumferentially disconnected. Here's the nidus gliotic margins. Some of the feeding vessels that are leading to the malformation. I continue to dissect around the nidus, step-by-step. Here's the more lateral wall of the nidus. Now working just underneath the nidus. Again, no navigation guides circumferential disconnection of the nidus. Here's the draining vein. Appears darker now. Here's disconnection nidus more anteriorly. Draining vein exiting the nidus. Now I'm working along the posterior border of the nidus. Again, staying outside the nidus. You can see the transfalcine approach especially useful here because he provides very acute angles, toward the lateral margin of the nidus. And ipsilateral approach or in other words, ipsilateral interhemispheric approach which require excessive hemispheric retraction to reach this very lateral pole of the malformation under direct vision. As expected, I entered the atrium. I made sure all the ependymal feeders are also disconnected. Here's more demagnified view of our operative corridor in relationship to the atrium. Here's the choroid plexus. Now the vein or the draining lane appears much darker and more collapsed. Ultimately the vein was also quite regulated and cut and the nidus was removed. Here's a viewing to our operative corridor. The resection cavity was carefully inspected and any suspicious material was also removed. Again, the very dark draining vein. Final view of the resection cavity, via their transfalcine approach. Ipsilateral hemisphere appears very healthy and the post-operative angiogram demonstrated complete exclusion of the malformation without any evidence of AV shunting. And three months MRI demonstrated no evidence of ischemia, and this patient made a remarkable recovery. Thank you.

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