The best method of dealing with complications is to avoid them. Therefore, any injury to the vertebral artery during a midline or paramedian suboccipital craniotomy should be avoided. All the patients can have a very dolichoectasic vertebral artery residing within the suboccipital muscles and somewhat outside the vertebral sulcus or sulcus arteriosus over the lateral aspect of C1. However, this is a young patient, an 18 year old female who presented with an spontaneous cerebellar intracranial hemorrhage and arteriovenous malformation was suspected. You can see the location of the blood clot. There is some hypervascularity along the superior and lateral aspect of the clot, signifying presence of a small malformation. This patient underwent a suboccipital craniotomy in a prone position. One of my colleagues conducted the initial steps of the operation. You can see that the dura was opened early on. However, the vertebral artery was injured during the exposure and dissection of the suboccipital muscles over the lateral aspect of the C1 at the area of the sulcus arteriosus. A temporary clip was placed at the area of the tear and the bleeding. You can see the more proximal aspect of the vertebral artery and its distal aspect over the C1. After I entered the operating room, I continue to dissect the vessel more proximaly. So proximal control can be secured. A temporary clip was inspected. You can see significant amount of bleeding from the area of the tear. Further dissection over the C1 allowed further proximal exposure. Temporary clip was placed proximally and distally to the initial tear. You can see the tear within the artery that is amenable to primary closure. Further dissection along the walls of that vessel is conducted. You can see this is a muscular branch of the vertebral artery that is left alone. A lumen was injured at this location. Eight or sutures were used to primarily close the defect. Further bleeding was encountered by relieving the distal temporary clip. Additional stitch was therefore placed at the suspected area of bleeding. After removal of the temporary clips, you can see that the artery is pulsatile, micro doppler, ultrasonography confirms adequate flow within that vessel. Subsequently I diverymactation to remove the malformation and the clot. This AVM was quite hypervascular. I do believe the AVM was underestimated initially due to compression from the clot, you can see the inlet into the floor of their fourth ventricle. Here's the final operative result. A postoperative CT scan demonstrates reasonable removal of the intracranial hemorrhage without any evidence of cerebellar ischemia. This patient recovered from the surgery without any other entoured effect. Thank you.
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