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Vermian AVM: Intraop Rupture-“Commando” Operation

January 07, 2016


Under the right circumstances, the commando operation is a very important measure in the hands of an experienced AVM surgeon for controlling massive complications. This maneuver can save the life of the patient during catastrophic intraoperative AVM rupture. This is a 52 year old male who presented with a ruptured large diffuse, vermain arteoriovenous malformation. At the initial time of the presentation, you can see that relatively sizable, cerebellar hematoma, albeit associated with a relatively unimpressive, Arteriovenous Malformation in the area of the superior Vermis. However, on the catheter conventional angiogram, you can see the diffuseness of this Vermian AVM associated with the branches of the superior cerebellar artery and draining into the vein of Galen along the midline hemispheric veins. Here's the later event phase of the Vertebral arterial injection, lateral view with again to diffuseness of this malformation is demonstrated. This patient underwent resection in a lateral position through a midline suboccipital craniotomy. You can see the bony opening in dural incision. The suppressor Balor route was chosen. You can see the draining vein, which is arterialized just joining the vein of Galen at this juncture. You can see there arterialized color of the vein. Joining the vein of Galen. The draining vein was identified early on, and then the superior part of the Vermis was Incised to reach the nicest of he malformation. Here is the superior part of the Vermis just under the tentorial that is being entered. One of the challenges here is that the feeding arteries were not initially controlled. And as I entered the malformation, I found myself dealing with quite amount of bleeding, which was really unstoppable. And I continued to work in the areas that I thought were margins of the malformation, but the diffuseness of the lesion, led to significant amount of bleeding and did not allow identification of bonafide margins. You can see the clot that was evacuated. I continued to extend my Vermian transection and work along where I thought the margins of the malformation would be nonetheless, the bleeding continued and I persisted and almost removed the AVM piecemeal until the gliotic margins of the malformation were identified. The deep white matter feeders were quite problematic here. You can see, especially on the left side, the bleeding is again daunting at times, but the surgeon has to remain patient, remain decisive, clear the field and remove the AVM as fast as possible to avoid life-threatening hemorrhage. Here's the portion of the malformation that is being removed, again if I had controlled the superior cerebellar artery feeding vessels early on, I could have potentially avoided that massive amount of bleeding. However, the diffuseness of this lesion most likely led to its technical difficulty following resection of the malformation hemostasis was obtained. This is the post operative angiogram, which demonstrates gross total resection of the malformation without any complicating feature. There are two important lessons in this video. Number one is understanding the diffuseness of the malformation that can play a significant role in the technical difficulty of dissection. I believe both eloquence and diffuseness of the malformation are two most important factors in complicating the safety of resection. The second important learning issue is persistence of the surgeon in the face of bleeding remaining patient composed and trying to find the margins of the malformation in the face of bleeding, to be able to remove the malformation as efficiently as possible as removal of the malformation is the only possible way to definitively control the bleeding. Thank you.

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