August 14, 2016
This is another case of a Basal Frontal Arteriovenous Malformation. This is a 15 year old female who presented with spontaneous intracerebral hemorrhage. CT angiogram demonstrated a relatively large, arteriovenous malformation along the right interior basal frontal lobe. The hematoma cavities primarily posterior to the nidus. An angiogram was completed to better define the angio-architecture of the malformation. Most of the feeding vessels are relatively, very small, very numerous, originating from both the ICA and the proximal M1. Also some of the feeding vessels originated from proximal A1. The drainage system, is primarily Basal frontal as expected with a large draining vein moving more posteriorly on the cortex. Shonda went a right fronto-temporal craniotomy. Here's the exposure Sylvian fissure. The frontal lobe was gently elevated, and the optic carotid cisterns were opened. Wide dissection of their arachnoid bands is necessary so that the frontal lobe can be mobilized and sub-frontal dissection along an oblique trajectory conducted on the AVM. Here's the internal coronary artery, optic nerve. Some of the feeding vessels to the malformation are readily visible. Use of dynamic retraction. Furthermore, the anterior limb of Sylvan fissure was split so that the feeding vessels traveling from M1 toward the nidus in this direction, are also identified individually and sacrificed. Here's the draining vein, highly arterialized in a view of the malformation along the basal frontal lobe. Some of the corkscrew vessels to the nidus traveling anteriorly toward the posterior border of the malformation were coagulated and cut. Obviously there arterialized veins were protected. Here's a cortical incision along the posterior aspect of the nidus just anterior to the Sylvian fissure located here. The following steps primarily involve circumferential disconnection of the malformation. I wanted to get into the hematoma cavity early on to provide further brain relaxation. Here's the Sylvian fissure. Here's the posterior basal frontal lobe. I continued to increase the depth of my corticotomy and hoped that I can reach the hematoma within the posterior border of the malformation. I was ultimately able to reach the hematoma cavity. As you can see here. Portion of the clot was evacuated. Next I, diverted my attention back to the disconnection of the nidus. Here is the lateral basal frontal lobe, where the malformation is more superficially disconnected. Here is the more interior part of the AVM. Again, numerous arterialized veins. I worked around the veins while disconnecting the malformation. I do not believe an orbitozygomatic craniotomy is necessary. If the arachnoid bands are widely dissected and dynamic retraction utilized. Here's a feeding vessel to the malformation, close to the arterialized vein, that was coagulated and cut. Still a fair amount of work is necessary to disconnect the malformation. Here's working along the anterior aspect of the malformation using CT angiogram navigation, for image guidance. The anterior border of the malformation was also better defined. Again, a large arterialized vein. Here's the more medial part of the basal frontal lobe. Arachnoid bands are a dissected away from the draining vein. You can see how I'm working between the veins. Here is dissection within the base of frontal lobe in close proximity of the fissure. Again I want to make sure all the small tiny M1 feeding vessels to the nidus are disconnected. After more superficial dissection, I continued to circumferentially go around the malformation. The deep white matter feeders are obviously problematic as expected. Additional cortical feeding vessel is disconnected, along the more anterior aspect of the AVM. To be able to mobilize the malformation, the smaller veins can be coagulated and cut as long as at least two dominant veins are present and able to shunt the AVM. You can see one of the more posterior veins was disconnected after temporary occlusion test. No nidal swelling was encountered, and therefore, I continued coagulation of the vein and it's disconnection. Here's part of the malformation that is being mobilized outside of our resection cavity. These two vessels were protected during the initial stages of the operation. However, there were later found to be feeding vessels to the malformation and coagulated and cut. Again, here is the part of the nidus staying outside the nidus within the white matter to complete the disconnection. Now working underneath one of the arterialized veins. Here is an arterialized vein most likely wrapping around the nidus at the apex of the malformation. Some of the deeper white matter feeders that are being coagulated. Going back to our hematoma cavity. Now the malformation again is being further mobilized anteriorly. Finally the malformation was removed. Next, I felt there was a small amount of nidus remaining this part of the nidus was leading toward the frontal horn of the lateral ventricle. This portion of the malformation was also excised. Here's a view of our operative cavity. I inspected the medial basal frontal lobe to make sure there is no unnecessary residual malformation. You can see the arterialized veins all appear very dark now. Here is one of them. Along the more anterior medial basal frontal lobe. There were some suspicious material that could be residual nidus. You can see some corkscrew vessels. This part of the cortex was heavily coagulated to assure complete removal of the malformation. Again this is the olfactory nerve there. Here, you can see some corkscrew vessels that are suspicious to be feeding vessels to the malformation. These corkscrew vessels were heavily coagulated. Here's the post-operative angiogram, which demonstrates complete removal of the malformation without any evidence of AV shunting. Post-operative CT scan revealed no complicating features and this patient made an excellent recovery. Thank you.
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