Microsurgical Resection of Ruptured Large Left Temporo-Occipital Arteriovenous Malformation: 3-Dimensional Operative Video

2018 ◽  
Vol 15 (6) ◽  
pp. E86-E86
Author(s):  
Chun-Yu Cheng ◽  
Rakshith Shetty ◽  
Laligam N Sekhar
Keyword(s):  
Arteriovenous Malformation ◽  
Cerebral Artery ◽  
Speech Therapy ◽  
Venous Drainage ◽  
Sigmoid Sinus ◽  
Preoperative Embolization ◽  
3 Dimensional ◽  
Vein Of Labbé ◽  
Microsurgical Resection ◽  
Martin Grade

Abstract A 59-yr-old man presented with intraventricular hemorrhage and was found to have a large temporo-occipital arteriovenous malformation (AVM), Spetzler–Martin grade 4. The preoperative intra-arterial digital subtraction angiography (IADSA) showed the AVM was 4 × 4 cm2, had superficial and deep venous drainage, and was fed by multiple branches of the posterior cerebral artery and middle cerebral artery. Preoperative embolization was done in 4 stages.  He underwent a left temporo-occipital craniotomy, mastoidectomy, and retrosigmoid craniotomy with a posterior temporal approach. Intraoperatively, there was a large draining vein draining into the sigmoid sinus in the location of the vein of Labbe, and multiple other feeding arteries and draining veins, including periventricular vessels. Circumferential dissection of the AVM was done from posteriorly, superiorly, anteriorly, and then inferiorly. The technique of temporary clipping and cauterizing the perforating arteries, and then sectioning them after flow arrest is shown in the video. Large arterial feeders were cauterized and divided. Three permanent aneurysm clips were left to control bleeding from the vessels of the trigone of the lateral ventricle. After the large draining vein into the sigmoid sinus was occluded, the AVM was completely removed. The patient had acute nonfluent aphasia postoperatively but improved after speech therapy. The postoperative IADSA demonstrated total resection. At 3-mo follow-up, he had recovered completely (mRS0).  This 3-D video shows the technical nuances of microsurgical resection of a complex large AVM.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Localization and Microsurgical Resection of Left Postcentral Gyrus Spetzler-Martin Grade 3 Arteriovenous Malformation by Intraoperative Neuronavigation and Tracing of Subcortical Draining Vein: 3-Dimensional Operative Video

2019 ◽  
Vol 19 (2) ◽  
pp. E185-E186
Author(s):  
Qazi Zeeshan ◽  
Juan P Carrasco Hernandez ◽  
Laligam N Sekhar
Keyword(s):  
Arteriovenous Malformation ◽  
Blood Clot ◽  
Preoperative Embolization ◽  
Facial Weakness ◽  
Cortical Vein ◽  
3 Dimensional ◽  
Postcentral Gyrus ◽  
Microsurgical Resection ◽  
Martin Grade ◽  
Grade 3

Abstract This 42-yr-old man presented with a history of sudden right-sided facial and right arm weakness and dysarthria. Head computed tomography showed a left frontal-parietal blood clot. An intra-arterial digital subtraction angiography demonstrated a left subcortical postcentral, Spetzler-Martin Grade 3 arteriovenous malformation (AVM) with a diffuse nidus, measuring 2.1 × 1.5 cm, supplied by branches of the left MCA, and draining into a cortical vein and a deep vein, which was going toward the ventricle. Preoperative embolization was not possible.  The patient underwent left frontal-parietal craniotomy with intraoperative motor and sensory mapping. No arterialized veins were visible on the cortical surface. Neuronavigation localized the AVM in the subcortical postcentral gyrus. Through an incision in the postcentral sulcus, microdissection led to a yellowish gliotic plane. The large cortical vein was in the gliotic area and traced to the AVM. Circumferential microdissection was performed around the AVM. It had a very diffuse nidus; the arterial feeders were cauterized and divided, and the superior superficial and inferior deep draining veins were finally occluded, and AVM was removed.  Postoperative angiogram showed total removal of the AVM. At discharge, his right arm weakness had improved (power 5/5), and facial weakness and dysarthria were improving (modified Rankin Scale (mRS) 2). At 1-yr follow-up, facial weakness and dysarthria had improved considerably, and patient returned to work (mRS 1).  This video shows microsurgical resection of an AVM by neuronavigation and tracing of the subcortical draining vein. The technique of cauterizing the perforating arteries after temporary clipping with flow arrest is shown in the video. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

scholarly journals Navigation-guided transsylvian approach and microsurgical resection of a deep left temporal low-grade arteriovenous malformation

2017 ◽  
Vol 43 (videosuppl1) ◽  
pp. V6
Author(s):  
William T. Couldwell
Keyword(s):  
Arteriovenous Malformation ◽  
Superior Temporal Gyrus ◽  
Adolescent Male ◽  
Low Grade ◽  
Link Type ◽  
Transsylvian Approach ◽  
Grade Ii ◽  
Microsurgical Resection ◽  
Martin Grade

This video demonstrates stereotactic-guided resection of a ruptured diffuse left temporal arteriovenous malformation (AVM) in an adolescent male who presented with headache and speech difficulties. The diffuse nidus of the AVM, 25 mm in size, was located in the posterior superior temporal gyrus, with drainage into the sylvian veins (Spetzler-Martin Grade II). The AVM was located stereotactically, and resection was performed through a small corticectomy. The clot cavity was evacuated. Feeding branches to the AVM were identified during careful dissection, and parent M1 and M2 branches were preserved. The patient recovered well, with no residual speech deficit. Postoperative angiogram demonstrated complete AVM removal.The video can be found here: https://youtu.be/Sttc86H8jCw.

Surgical Management Of Posterior Fossa Arteriovenous Malformations

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-189-ONS-201 ◽  
Author(s):  
John Sinclair ◽  
Michael E. Kelly ◽  
Gary K. Steinberg
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Cerebellar Nuclei ◽  
Preoperative Embolization ◽  
Frameless Stereotaxy ◽  
Microsurgical Resection

Abstract Objective: Arteriovenous malformations (AVMs) involving the cerebellum and brainstem are relatively rare lesions that most often present clinically as a result of a hemorrhagic episode. Although these AVMs were once thought to have a more aggressive clinical course in comparison with supratentorial AVMs, recent autopsy data suggests that there may be little difference in hemorrhage rates between the two locations. Although current management of these lesions often involves preoperative embolization and stereotactic radiosurgery, surgical resection remains the treatment of choice, conferring immediate protection to the patient from the risk of future hemorrhage. Methods: Most symptomatic AVMs that involve the cerebellum and the pial or ependymal surfaces of the brainstem are candidates for surgical resection. Preoperative angiography and magnetic resonance imaging studies are critical to determine suitability for resection and choice of operative exposure. In addition to considering the location of the nidus, arterial supply, and predominant venous drainage, the surgical approach must also be selected with consideration of the small confines of the posterior fossa and eloquence of the brainstem, cranial nerves, and deep cerebellar nuclei. Results: Since the 1980s, progressive advances in preoperative embolization, frameless stereotaxy, and intraoperative electrophysiologic monitoring have significantly improved the number of posterior fossa AVMs amenable to microsurgical resection with minimal morbidity and mortality. Conclusion: Future improvements in endovascular technology and stereotactic radiosurgery will likely continue to increase the number of posterior fossa AVMs that can safely be removed and further improve the clinical outcomes associated with microsurgical resection.

scholarly journals Microsurgical resection of previously embolized recurrent cerebellopontine angle AVM

2021 ◽  
Vol 4 (1) ◽  
pp. V2
Author(s):  
Ehsan Dowlati ◽  
Kelsi Chesney ◽  
Vikram V. Nayar
Keyword(s):  
Arteriovenous Malformation ◽  
Indocyanine Green ◽  
Endovascular Treatment ◽  
Cerebellopontine Angle ◽  
Indocyanine Green Angiography ◽  
Transverse Sinus ◽  
Grade Ii ◽  
Microsurgical Resection ◽  
Martin Grade

This is the case of a ruptured Spetzler-Martin grade II arteriovenous malformation (AVM) located in the cerebellopontine angle and draining into the transverse sinus. The AVM was initially treated with staged embolization using Onyx (ev3 Neurovascular). However, recurrence was noted and treatment with microsurgical resection was undertaken. The authors present technical nuances of the approach and strategies for microsurgical resection of a previously embolized recurrent AVM with the aid of intraoperative indocyanine green angiography. Follow-up after endovascular treatment is critical, and curative treatment with microsurgical resection can be achieved with low morbidity in such AVMs as demonstrated by this case.The video can be found here: https://youtu.be/LMpz_YTFC0g

scholarly journals Left Parietal Craniotomy for Resection of Grade IV Arteriovenous Malformation: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (4) ◽  
pp. E113-E113
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cerebral Artery ◽  
Video Recording ◽  
Complete Removal ◽  
Complete Recovery ◽  
Preoperative Embolization ◽  
Institutional Review ◽  
Postcentral Gyrus ◽  
Feeding Vessels ◽  
Martin Grade ◽  
Occipital Pole

Abstract Parieto-occipital arteriovenous malformations (AVMs) are the second most common site for cranial AVMs. These lesions are defined as eloquent when the nidus involves either the postcentral gyrus or the occipital pole. If located on the dominant hemisphere, these lesions can also involve the arcuate fasciculus ventrally. This patient had a large unruptured Spetzler-Martin grade IV AVM within the parieto-occipital region extending deeply to the ventricle, following presentation with a seizure. The digital subtraction angiography demonstrated feeding vessels from both the middle cerebral artery and posterior cerebral artery distributions. Despite the high Spetzler-Martin grade, the lesion demonstrated favorable features such as a compact nidus, convexity presence, and lack of involvement of the precentral and postcentral gyrus. Preoperative embolization was utilized. The AVM was successfully resected both superficially and deeply to the level of the atrium of the lateral ventricle. Postoperative angiography demonstrated complete removal of the AVM, and the patient made a complete recovery from the procedure. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience

2015 ◽  
Vol 15 (1) ◽  
pp. 71-77 ◽  
Author(s):  
Bradley A. Gross ◽  
Armide Storey ◽  
Darren B. Orbach ◽  
R. Michael Scott ◽  
Edward R. Smith
Keyword(s):  
Arteriovenous Malformations ◽  
Neurological Complications ◽  
Neurological Deficits ◽  
Preoperative Embolization ◽  
Recurrence Rates ◽  
Microsurgical Treatment ◽  
Obliteration Rate ◽  
Microsurgical Resection ◽  
Martin Grade ◽  
Cerebral Avms

OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0–2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.

scholarly journals Microsurgical Resection of Brainstem Arteriovenous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E38-E38
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Radiation Treatment ◽  
Video Recording ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Mass Effect ◽  
Fiber Tracts ◽  
Institutional Review ◽  
Ventriculoperitoneal Shunting ◽  
Microsurgical Resection ◽  
Martin Grade

Abstract Brainstem arteriovenous malformations (AVMs) are rare lesions (2%-6% of all intracranial AVMs) that are surgically challenging because of the high eloquence of the brainstem, including dense fiber tracts, cranial nerves, and multiple vital cerebrovascular structures. All these lesions possess eloquence and deep venous drainage, making them innately Spetlzer–Martin grade III or above. This patient had a large midbrain AVM with a complex clinical course beginning with ventriculoperitoneal shunting due to mass effect; the patient experienced 4 hemorrhages, underwent radiation treatment, and finally underwent surgical resection. The surgical approach involved a large torcular craniotomy exposing all posterior sinuses at the confluence. The vein of Galen was exposed and carried deeply to permit ambient cistern opening and relaxation of the cerebellum. Because of earlier radiation therapy, the vessels had undergone hyalinosis, which resulted in difficult manipulation of the nidus but did permit excellent coagulation of the vessels. The complete nidus was removed, as confirmed on postoperative angiography. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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