Contralateral Anterior Interhemispheric Approach to Medial Frontal Arteriovenous Malformations: Surgical Technique and Results

2017 ◽  
Vol 13 (4) ◽  
pp. 413-420 ◽  
Author(s):  
Ahmad Hafez ◽  
Kunal P. Raygor ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Angle Of Attack ◽  
Lateral Margin ◽  
Safe Alternative ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Anterior Interhemispheric Approach ◽  
Interhemispheric Fissure ◽  
Radiographic Data

Abstract BACKGROUND: Medial frontal arteriovenous malformations (AVMs) require opening the interhemispheric fissure and are traditionally accessed through an ipsilateral anterior interhemispheric approach (IAIA). The contralateral anterior interhemispheric approach (CAIA) flips the positioning with the midline still positioned horizontally for gravity retraction, but with the AVM on the upside and the approach from the contralateral, dependent side. OBJECTIVE: To determine whether the perpendicular angle of attack associated with the IAIA converts to a more favorable parallel angle of attack with the CAIA. METHODS: The CAIA was used in 6 patients with medial frontal AVMs. Patients and AVM characteristics, as well as pre- and postoperative clinical and radiographic data, were reviewed retrospectively. RESULTS: Four patients presented with unruptured AVMs, with 5 AVMs in the dominant, left hemisphere. The lateral margin was off-midline in all cases, and average nidus size was 2.3 cm. All AVMs were resected completely, as confirmed by postoperative catheter angiography. All patients had good neurological outcomes, with either stable or improved modified Rankin Scores at last follow-up. CONCLUSIONS: This study demonstrates that the CAIA is a safe alternative to the IAIA for medial frontal AVMs that extend 2 cm or more off-midline into the deep frontal white matter. The CAIA aligns the axis of the AVM nidus parallel to the exposure trajectory, brings its margins in view for circumferential dissection, allows gravity to deliver the nidus into the interhemispheric fissure, and facilitates exposure of the lateral margin for the final dissection, all without resecting or retracting adjacent normal cortex.

scholarly journals Contralateral posterior interhemispheric approach to deep medial parietooccipital vascular malformations: surgical technique and results

2018 ◽  
Vol 129 (1) ◽  
pp. 198-204 ◽  
Author(s):  
Jan-Karl Burkhardt ◽  
Ethan A. Winkler ◽  
Michael T. Lawton
Keyword(s):  
Vascular Malformations ◽  
Angle Of Attack ◽  
Patient Positioning ◽  
Safe Alternative ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Alternative Approach ◽  
Scale Scores ◽  
Lateral Margins

OBJECTIVEDeep medial parietooccipital arteriovenous malformations (AVMs) and cerebral cavernous malformations (CCMs) are traditionally resected through an ipsilateral posterior interhemispheric approach (IPIA), which creates a deep, perpendicular perspective with limited access to the lateral margins of the lesion. The contralateral posterior interhemispheric approach (CPIA) flips the positioning, with the midline positioned horizontally for retraction due to gravity, but with the AVM on the upper side and the approach from the contralateral, lower side. The aim of this paper was to analyze whether the perpendicular angle of attack that is used in IPIA would convert to a parallel angle of attack with the CPIA, with less retraction, improved working angles, and no significant increase in risk.METHODSA retrospective review of pre- and postoperative clinical and radiographic data was performed in 8 patients who underwent a CPIA.RESULTSThree AVMs and 5 CCMs were resected using the CPIA, with an average nidus size of 2.3 cm and CCM diameter of 1.7 cm. All lesions were resected completely, as confirmed on postoperative catheter angiography or MRI. All patients had good neurological outcomes, with either stable or improved modified Rankin Scale scores at last follow-up.CONCLUSIONSThe CPIA is a safe alternative approach to the IPIA for deep medial parietooccipital vascular malformations that extend 2 cm or more off the midline. Contralaterality and retraction due to gravity optimize the interhemispheric corridor, the surgical trajectory to the lesion, and the visualization of the lateral margin, without resection or retraction of adjacent normal cortex. Although the falx is a physical barrier to accessing the lesion, it stabilizes the ipsilateral hemisphere while gravity delivers the dissected lesion through the transfalcine window. Patient positioning, CSF drainage, venous preservation, and meticulous dissection of the deep margins are critical to the safety of this approach.

Bifrontal interhemispheric approach to aneurysms of the anterior communicating artery

1986 ◽  
Vol 64 (2) ◽  
pp. 183-190 ◽  
Author(s):  
Jiro Suzuki ◽  
Kazuo Mizoi ◽  
Takashi Yoshimoto
Keyword(s):  
Cerebral Arteries ◽  
Distal Portion ◽  
Anterior Communicating Artery ◽  
Content Type ◽  
Interhemispheric Approach ◽  
Interhemispheric Fissure ◽  
Early Operations ◽  
Temporary Clip ◽  
Fine Print

✓ The authors review their experience with the bifrontal interhemispheric approach in 603 cases of single anterior communicating artery (ACoA) aneurysms and describe the operative technique. With this approach, the olfactory tracts are dissected, and both A1 segments of the anterior cerebral arteries are identified subfrontally. The interhemispheric fissure is then dissected and A2segments are followed from the distal portion toward the ACoA complex. Following the administration of a combination of mannitol, vitamin E, and dexamethasone, a temporary clip is placed on at least the dominant A1 segment prior to dissection of the aneurysm itself. Once the aneurysm has been completely freed from the surrounding structures, the neck is ligated and clipped. If the aneurysm ruptures during surgery, temporary clips are placed on both A1 and A2 segments bilaterally and the operation proceeds in a completely dry field. With this method, it is possible to occlude any of the intracranial vessels for up to 40 minutes within 100 minutes of drug administration. To prevent the possibility of rerupture and the development of vasospasm in the period before aneurysm surgery, the authors have adopted a policy of performing ultra-early operations within 48 hours of the onset of symptoms. Among the 257 cases operated on during the 9 years since 1975, one-fifth have been operated on within 48 hours of rupture, and the in-hospital mortality rate has been only 4.3% (11 cases). Follow-up studies have shown that 87% of the 246 surviving patients have returned to useful lives.

scholarly journals Adenosine-induced Cardiac Standstill to Facilitate Endovascular Embolisation of Cerebral Arteriovenous Malformations in Children

2009 ◽  
Vol 37 (4) ◽  
pp. 619-623 ◽  
Author(s):  
G. D. Puri ◽  
I. Sen ◽  
J. R. Bapuraj
Keyword(s):  
General Anaesthesia ◽  
Arteriovenous Malformations ◽  
High Flow ◽  
Cerebral Arteriovenous Malformations ◽  
Neurological Outcomes ◽  
Endovascular Embolisation ◽  
Glue Injection ◽  
Controlled Deposition ◽  
One Year

This report describes three children, aged eight to 11 years, with high-flow cerebral arteriovenous malformations who underwent interventional neuroradiological procedures involving glue (N-butyl cyanoacrylate) embolisation under general anaesthesia. The procedure was facilitated by relative hypotension induced by esmolol infusion and intravenous adenosine boluses. To allow controlled deposition of N-butyl cyanoacrylate into the arteriovenous malformations, glue injection was synchronised with the onset of adenosine-induced brief cardiac standstill. This resulted in satisfactory obliteration of the arteriovenous malformations nidus in all cases. The haemodynamic modulations, including the adenosine-induced brief cardiac standstill, was noted to not affect the BIS values in our patients. All patients had satisfactory obliteration of their arteriovenous malformations and had good neurological outcomes at one-year follow-up.

Posterior Interhemispheric Approach: Surgical Technique, Application to Vascular Lesions, and Benefits of Gravity Retraction

2006 ◽  
Vol 59 (suppl_1) ◽  
pp. ONS-41-ONS-49 ◽  
Author(s):  
John H. Chi ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Artery Aneurysm ◽  
Occipital Lobe ◽  
Vascular Lesions ◽  
Arteriovenous Fistulae ◽  
Cavernous Malformations ◽  
Neurological Outcomes ◽  
Interhemispheric Approach ◽  
Occipital Lobes ◽  
Posterior Midline

Abstract OBJECTIVE: To review an experience with the posterior interhemispheric approach applied to vascular lesions in the posterior midline, to examine the effects of patient position and gravity retraction of the occipital lobe, and to identify circumstances requiring increased exposure by sectioning the falx and tentorium. METHODS: During a 6.5-year period, 46 posterior interhemispheric approaches were performed to treat 28 arteriovenous malformations, 10 dural arteriovenous fistulae, seven cavernous malformations, and one posterior cerebral artery aneurysm. Twenty-three patients were positioned prone and 23 patient were positioned laterally. RESULTS: A standard posterior interhemispheric approach was used in 38 patients, and the occipital bitranstentorial/falcine approach was used in seven patients. A contralateral occipital transfalcine approach was used with one thalamic cavernous malformation. All lesions were resected completely and/or obliterated angiographically, with good neurological outcomes in 83% of patients and no operative mortality. Blood loss was lower, operative durations were shorter, postoperative cerebral edema was decreased, and visual outcomes were improved in patients positioned laterally. CONCLUSION: The posterior interhemispheric approach, without additional dural cuts, is appropriate for most vascular lesions in the posterior midline. Gravity retracts the occipital lobes when patients are positioned laterally, enhancing operative exposure and reducing morbidity. Extension of the posterior interhemispheric approach to a transtentorial or transfalcine approach is required for falcotentorial dural arteriovenous fistulae and vein of Galen arteriovenous malformations, but is not usually necessary with cavernous malformations or other arteriovenous malformations.

scholarly journals Contralateral Transfalcine Versus Ipsilateral Anterior Interhemispheric Approach for Midline Arteriovenous Malformations: Surgical and Anatomical Assessment

2018 ◽  
Vol 119 ◽  
pp. e1041-e1051 ◽  
Author(s):  
Sergio García-García ◽  
José Juan González-Sánchez ◽  
Sirin Gandhi ◽  
Halima Tabani ◽  
Ali Tayebi Meybodi ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Interhemispheric Approach ◽  
Anterior Interhemispheric Approach

Effect of Presenting Hemorrhage on Outcome after Microsurgical Resection of Brain Arteriovenous Malformations

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. 485-493 ◽  
Author(s):  
Michael T. Lawton ◽  
Rose Du ◽  
Mary Nelson Tran ◽  
Achal S. Achrol ◽  
Charles E. McCulloch ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Predictor Variable ◽  
Consecutive Series ◽  
Surgical Morbidity ◽  
Elective Resection ◽  
Neurological Outcomes ◽  
Improved Outcomes ◽  
Increased Risk ◽  
Microsurgical Resection

Abstract OBJECTIVE: We hypothesized that patients with unruptured arteriovenous malformations (AVMs) at presentation have an increased risk of deterioration compared with patients with ruptured AVMs. METHODS: A consecutive series of 224 patients treated microsurgically by a single neurosurgeon during a period of 6.4 years was analyzed. Initial hemorrhagic presentation was the primary predictor variable. Neurological outcomes were assessed by use of the Modified Rankin Scale (MRS) and Glasgow Outcome Scale (GOS), and logistic regression identified predictors of deterioration at follow-up (mean duration, 1.3 yr) relative to baseline before any intervention. RESULTS: Overall, 120 patients (54%) presented with hemorrhage, and all 224 patients underwent microsurgical resection. Complete resection was achieved in 220 patients (98%). According to GOS score, 13 patients (5.8%) deteriorated; according to MRS score, 45 patients (20.1%) deteriorated. Fifteen patients (6.7%) died. Hemorrhagic presentation was associated with improved outcomes, with a mean change in MRS score of +0.89 in patients with ruptured AVMs and −0.38 in patients with unruptured AVMs (P < 0.001). The final mean MRS scores in patients with unruptured AVMs were better than those in patients with ruptured AVMs (1.44 versus 1.90; P = 0.048). Presentation with an unruptured AVM was a predictor of worsening MRS score (odds ratio, 2.33; 95% confidence interval, 1.3–4.3; P = 0.006) but not of worsening GOS score. CONCLUSION: Presentation with AVM hemorrhage is an underappreciated predictor of outcome after therapy that includes microsurgical resection. Patients with ruptured AVMs tended to have deficits at presentation and generally improved after surgery, whereas patients with unruptured AVMs tended to have normal or nearly normal neurological function at presentation and were susceptible to worsening, albeit slight, as measured by MRS scores. Sensitive outcome measures such as MRS detect subtle symptoms and impairments missed by coarser measures such as GOS. Patients should be counseled that the risks associated with elective resection of unruptured AVMs may be higher than recognized previously. Hemorrhagic brain injury and its secondary effects may mask this surgical morbidity.

scholarly journals Anterior Interhemispheric Approach in Craniopharyngiomas : Personal Experience of Operative Technique and Results

2018 ◽  
Vol 6 (2) ◽  
pp. 7-10
Author(s):  
Jaideep Chandra ◽  
Santosh Shah
Keyword(s):  
Personal Experience ◽  
Age Group ◽  
Total Excision ◽  
Pediatric Age Group ◽  
Interhemispheric Approach ◽  
Anterior Interhemispheric Approach ◽  
Brain Interface ◽  
Midline Approach ◽  
Disease Free

Introduction: Removal of intracranial supra-sellar masses continues to be a surgical challenge. Various approaches have been used by different authors with varying results. Anterior basal interhemispheric approach is most suitable with better results than other approaches for craniopharyngiomas Materials and methods: Fifteen patients with large craniopharyngiomas having third ventricular and or retro or supra-sellar extensions or reaching the interpeduncular cisterns were operated by this approach, over a period of seven years since the first use of this approach at our institute. The data of patients opearated by this approach were then retrospectively analysed. There were eleven males and four females with five patients in the pediatric age group. Follow up range was from 2 to 83 months with a mean of 21.6 months. Results: Total excision was achieved in seven (46.6%) and near total excision in another seven (46.6%), partial excision was done in only one (6.66%). Seven patients with total excision were disease free at mean follow up of 6.8 months. There was asymptomatic recurrence in two (13.33%) patient with near total excision at 11 and 63 months respectively and were given radiotherapy post-operatively. All patients were symptom free except one with diabetes insipidus (DI) and one mortality, and one with post operative visual deterioration. Conclusion: Anterior basal interhemispheric approach is a useful alternative to other transcranial approaches in the management of the craniopharyngiomas. It has the advantage of being a midline approach and displays the tumour brain interface better. 

Anterior Interhemispheric Approach for 100 Tumors in and Around the Anterior Third Ventricle

2010 ◽  
Vol 66 (suppl_1) ◽  
pp. ons-65-ons-74 ◽  
Author(s):  
Tomokatsu Hori ◽  
Takakazu Kawamata ◽  
Kosaku Amano ◽  
Yasuo Aihara ◽  
Masami Ono ◽  
...  
Keyword(s):  
Third Ventricle ◽  
Karnofsky Performance Scale ◽  
Subtotal Resection ◽  
Anterior Communicating Artery ◽  
Lamina Terminalis ◽  
Interhemispheric Approach ◽  
Anterior Interhemispheric Approach ◽  
Bridging Veins ◽  
Performance Scale

Abstract Objective: We report our experience with anterior interhemispheric approach for tumors in and around the anterior third ventricle, including surgical technique, instrumentation, pre- and postoperative hormonal disturbances, and resection rate. Methods: One hundred patients with 46 craniopharyngiomas, 12 hypothalamic gliomas, 12 meningiomas, 6 hypothalamic hamartomas, and 24 other lesions were operated on using an anterior interhemispheric approach with or without opening of the lamina terminalis. This surgical approach involves no frontal sinus opening; a narrow (approximately 15–20 mm in width) access between the bridging veins, which is sufficient to remove the tumor totally; and sparing of the anterior communicating artery. Specially designed long bipolar forceps and scissors are necessary for this approach, and concomitant use of angled instruments (endoscope, aspirator, and microforceps) is required frequently. The postsurgical follow-up period varied from 4 months to 18 years. Results: Total removal of the neoplasm was accomplished in 37 of 46 patients with craniopharyngiomas (80.4%), whereas subtotal resection was performed in hypothalamic gliomas. No significant differences in pre- and postoperative hormonal disturbances were observed in 37 craniopharyngiomas and 10 hypothalamic gliomas. There was no operative mortality. Visual acuity was preserved or improved in 68 of 75 patients assessed. The Karnofsky Performance Scale score did not deteriorate in 72 of 75 patients tested. Conclusion: The minimally invasive anterior interhemispheric approach, with or without opening of the lamina terminalis, is useful for removal of tumors in and around the anterior third ventricle, such as craniopharyngiomas and hypothalamic gliomas.

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