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

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.

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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

Operative Neurosurgery ◽

10.1093/ons/opz383 ◽

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.

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Orbitozygomatic Craniotomy for Clipping a Complex Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz314 ◽

2019 ◽

Vol 18 (2) ◽

pp. E33-E33

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Video Recording ◽

Artery Aneurysm ◽

Sylvian Fissure ◽

Parent Artery ◽

Parent Vessel ◽

Institutional Review ◽

Vessel Patency ◽

Mca Aneurysm

Abstract Middle cerebral artery (MCA) aneurysms pose a surgical challenge because of the large caliber of the parent artery and the common need to dissect the sylvian fissure to permit access to the proximal and distal control. The neck of the aneurysm should be generously dissected to permit visualization of any adjacent lenticulostriate perforators. This patient demonstrated a left-sided wide-necked bilobed MCA aneurysm at the M1 bifurcation. The aneurysm was approached using a left orbitozygomatic craniotomy with distal sylvian fissure dissection. A single curved clip was applied for aneurysm occlusion, and postoperative angiography demonstrated aneurysm obliteration with parent vessel patency. 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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Surgical Management of a Ruptured Dissecting Anterior Cerebral Artery (A2) Aneurysm Utilizing Contralateral Frontopolar for Reconstruction: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz405 ◽

2019 ◽

Vol 18 (3) ◽

pp. E76-E77

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Video Recording ◽

Dissecting Aneurysm ◽

Institutional Review ◽

Interhemispheric Fissure ◽

Diseased Vessel ◽

Temporary Clip ◽

Rupture Site ◽

Fibrin Thrombus

Abstract Dissecting aneurysms can pose an immense surgical challenge, and intervention often involves high risk for rerupture because of the volatile nature of the fibrin thrombus overlying the rupture site. This patient presented following rupture of a dissecting aneurysm along the A2 segment of the anterior cerebral artery (ACA). The patient underwent a right orbitozygomatic craniotomy, and the aneurysm was approached within the interhemispheric fissure. Manipulation of the aneurysm dome resulted in intraoperative rerupture of the aneurysm, which was controlled by the application of a temporary clip on the parent A2 proximally and distally. Aneurysmectomy of the thin diseased vessel wall was performed. The defect was filled by transecting the frontopolar branch of the ACA and sewing the frontopolar branch onto the aneurysmectomy defect. This provided a suitable patch for the ACA defect. Postprocedural indocyanine green angiography demonstrated patency of the A2 and the anastomosed frontopolar branch. 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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Supracerebellar Transtentorial Approach for Mesial Temporal Lobe Cavernous Malformation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz257 ◽

2019 ◽

Vol 17 (6) ◽

pp. E236-E236 ◽

Cited By ~ 1

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Cavernous Malformation ◽

Video Recording ◽

Complete Removal ◽

Institutional Review Board ◽

Cavernous Malformations ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Stereotactic Navigation ◽

Mesial Temporal Lobe ◽

Transtentorial Approach

Abstract Medial temporal cavernous malformations can involve transgression of eloquent parenchyma. For a tentorium-abutting temporal cavernous malformation, the supracerebellar transtentorial corridor is a suitable approach with minimal parenchymal insult. Using dynamic and gravity retraction, lighted bipolar forceps and suction, and stereotactic navigation, this trajectory provides a minimally invasive corridor. The patient in this case has a medial temporal cavernous malformation, with the lesion abutting the tentorial leaflet. The cavernous malformation is accessed and removed in a piecemeal manner. Complete removal of the lesion is achieved. The patient remained neurologically stable after 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.

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Left Modified Orbitozygomatic Approach for Clipping of Multilobulated Middle Cerebral Artery Bifurcation Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa179 ◽

2020 ◽

Vol 19 (4) ◽

pp. E386-E386 ◽

Cited By ~ 1

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Video Recording ◽

Parent Vessel ◽

Microsurgical Treatment ◽

Institutional Review ◽

Bifurcation Aneurysm ◽

Orbitozygomatic Approach ◽

Clip Application ◽

Clip Occlusion

Abstract Middle cerebral artery (MCA) aneurysms are associated with one of the most favorable approaches for microsurgical treatment; however, aneurysm geometrics can pose challenges during clip application. The surgeon must be mindful of the clip configuration options available during the planning of ideal clip occlusion for irregular or multilobulated aneurysm domes. This patient had an incidental multilobulated MCA bifurcation aneurysm and underwent an orbitozygomatic approach for microsurgical treatment. Proximal and distal control of the aneurysm were achieved, and complete clip occlusion was achieved following the placement of a single permanent clip. Flow within the parent vessel was well preserved, and complete aneurysm occlusion was achieved. 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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Moyamoya Disease Superficial Temporal Artery-to-Middle Cerebral Artery Onlay: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa039 ◽

2020 ◽

Vol 18 (6) ◽

pp. E229-E229

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Moyamoya Disease ◽

Cerebral Artery ◽

Superficial Temporal Artery ◽

Video Recording ◽

Temporal Artery ◽

Low Flow ◽

Institutional Review ◽

Direct Anastomosis

Abstract The most frequently performed low-flow bypass procedure is the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. If available, a suitable M2 or M3 cortical branch is anastomosed to the donor vessel. This patient had severe moyamoya disease with an ipsilateral perfusion deficit and transient ischemic attacks. Given the need for revascularization, an STA-to-MCA bypass was performed. There was no suitable recipient M3 branch for direct anastomosis, and therefore an indirect bypass was performed by onlaying the STA onto the cortical surface and suturing the adventitia of the STA to the arachnoid of the underlying cortex. The dural leaflets were then inverted to potentiate further revascularization of the underlying cortex. The patient remained at their neurological baseline and demonstrated an enhanced perfusion of the ipsilateral MCA territory on follow-up evaluation. 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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Bonnet Bypass for Left Superficial Temporal Artery Bifurcation to Right Middle Cerebral Artery: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz245 ◽

2019 ◽

Vol 17 (5) ◽

pp. E201-E202 ◽

Cited By ~ 1

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Saphenous Vein ◽

Superficial Temporal Artery ◽

Video Recording ◽

Temporal Artery ◽

Interposition Graft ◽

Institutional Review ◽

Bypass Patency ◽

Pass Through

Abstract A bonnet bypass is a long interposition graft bypass used for extracranial to intracranial revascularization, which is useful in patients who do not have a suitable ipsilateral donor or in whom the ipsilateral donor must be sacrificed. This interposition graft is commonly the radial artery or saphenous vein. The only practical difference in this technique for revascularization is that an interposition graft must pass through the subgaleal space to the contralateral scalp to allow for reimplantation at the desired contralateral point of anastomosis. This patient underwent a bonnet bypass for revascularization of the middle cerebral artery (MCA) perfusion territory utilizing the contralateral superficial temporal artery (STA). A saphenous vein was used as the interposition graft, which was anastomosed to an M2 segment bifurcation. The graft was then temporarily occluded and passed within a calvarial trough to the contralateral frontoparietal region. The graft was then anastomosed to the contralateral STA at a bifurcation to accommodate the graft size mismatch. The patient tolerated the bypass procedure well and demonstrated bypass patency on postoperative angiographic imaging. 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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A3-A3 Bypass for Giant Anterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa052 ◽

2020 ◽

Vol 19 (1) ◽

pp. E47-E48

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Video Recording ◽

Artery Aneurysm ◽

Distal Segment ◽

Institutional Review ◽

Diseased Vessel ◽

Distal Perfusion ◽

The Right ◽

Cerebral Artery Aneurysm

Abstract Large fusiform anterior cerebral artery aneurysms often require revascularization to allow for the treatment of the aneurysm and preservation of distal perfusion. The A3-A3 side-to-side anastomosis maintains ipsilateral distal perfusion. The inflow to the fusiform segment can then be clip occluded to treat the diseased vessel segment. This procedure is illustrated by the case in this video. The patient had a large right anterior cerebral artery fusiform aneurysm. An anterior interhemispheric craniotomy with the right side down was utilized for the approach. Postprocedural angiography demonstrated occlusion of the aneurysmal segment and patent distal perfusion within the ipsilateral distal segment. 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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Microsurgical Resection of Ruptured Large Left Temporo-Occipital Arteriovenous Malformation: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy118 ◽

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.

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Clipping of Basilar and Middle Cerebral Artery Aneurysms: 2-dimensional operative video

Operative Neurosurgery ◽

10.1093/ons/opaa116 ◽

2020 ◽

Vol 19 (3) ◽

pp. E290-E290

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Preoperative Planning ◽

Video Recording ◽

Surgical Clipping ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Complete Obliteration ◽

Mca Aneurysm ◽

Middle Cerebral Artery Aneurysms

Abstract Careful preoperative planning for patients with multiple intracranial aneurysms is paramount given the importance of an appropriate trajectory and exposure for each aneurysm that will be clipped. The general principle is to clip aneurysms in a retrograde manner, such that more distal aneurysms are clipped earlier, and more superficial aneurysms are clipped later. This patient had unruptured middle cerebral artery (MCA) and basilar artery (BA) apex aneurysms and elected for surgical clipping of both lesions. An orbitozygomatic craniotomy ipsilateral to the MCA aneurysm was performed to permit clipping of both lesions. The dissection initially focused on exposure of the MCA aneurysm and then focused on the carotid-oculomotor triangle to permit basilar apex exposure and aneurysm clipping. The MCA aneurysm was clipped second. Postoperative imaging demonstrated complete obliteration of both aneurysms. 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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