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.

Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations

2018 ◽  
Vol 15 (4) ◽  
pp. 404-411 ◽  
Author(s):  
Justin Mascitelli ◽  
Jan-Karl Burkhardt ◽  
Sirin Gandhi ◽  
Michael T Lawton
Keyword(s):  
Intraoperative Complications ◽  
Occipital Lobe ◽  
Senior Author ◽  
Pineal Region ◽  
Neurological Deficits ◽  
Cavernous Malformations ◽  
Posterior Thalamus ◽  
Neurological Outcomes ◽  
The Right ◽  
Brain Retraction

Abstract BACKGROUND Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium. OBJECTIVE To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs. METHODS From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient. RESULTS All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively. CONCLUSION This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.

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.

Modified classification of spinal cord vascular lesions

2002 ◽  
Vol 96 (2) ◽  
pp. 145-156 ◽  
Author(s):  
Robert F. Spetzler ◽  
Paul W. Detwiler ◽  
Howard A. Riina ◽  
Randall W. Porter
Keyword(s):  
Spinal Cord ◽  
Classification System ◽  
Arteriovenous Malformations ◽  
Vascular Malformations ◽  
Relevant Literature ◽  
Vascular Lesions ◽  
Cavernous Malformations ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Fine Print

The literature on spinal vascular malformations contains a great deal of confusing terminology. Some of the nomenclature is inconsistent with the lesions described. Based on the experience of the senior author (R.F.S.) in the treatment of more than 130 spinal cord vascular lesions and based on a thorough review of the relevant literature, the authors propose a modified classification system for spinal cord vascular lesions. Lesions are divided into three primary or broad categories: neoplasms, aneurysms, and arteriovenous lesions. Neoplastic vascular lesions include hemangioblastomas and cavernous malformations, both of which occur sporadically and familially. The second category consists of spinal aneurysms, which are rare. The third category, spinal cord arteriovenous lesions, is divided into arteriovenous fistulas and arteriovenous malformations (AVMs). Arteriovenous fistulas are subdivided into those that are extradural and those that are intradural, with intradural lesions categorized as either dorsal or ventral. Arteriovenous malformations are subdivided into extradural-intradural and intradural malformations. Intradural lesions are further divided into intramedullary, intramedullary-extramedullary, and conus medullaris, a new category of AVM. This modified classification system for vascular lesions of the spinal cord, based on pathophysiology, neuroimaging features, intraoperative observations, and neuroanatomy, offers several advantages. First, it includes all surgical vascular lesions that affect the spinal cord. Second, it guides treatment by classifying lesions based on location and pathophysiology. Finally, it eliminates the confusion produced by the multitude of unrelated nomenclatural terms found in the literature.

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 Overview of Neo-Vascular Lesions after Delivery or Miscarriage

2021 ◽  
Vol 10 (5) ◽  
pp. 1084
Author(s):  
Yuji Shiina
Keyword(s):  
Arteriovenous Malformations ◽  
Uterine Artery ◽  
Spontaneous Regression ◽  
Vascular Diseases ◽  
Vascular Lesions ◽  
Artery Pseudoaneurysm ◽  
Retained Products Of Conception ◽  
Products Of Conception ◽  
Uterine Artery Pseudoaneurysm ◽  
Retained Products

The concept of intrauterine neo-vascular lesions after pregnancy, initially called placental polyps, has changed gradually. Now, based on diagnostic imaging, such lesions are defined as retained products of conception (RPOC) with vascularization. The lesions appear after delivery or miscarriage, and they are accompanied by frequent abundant vascularization in the myometrium attached to the remnant. Many of these vascular lesions have been reported to resolve spontaneously within a few months. Acquired arteriovenous malformations (AVMs) must be considered in the differential diagnosis of RPOC with vascularization. AVMs are errors of morphogenesis. The lesions start to be constructed at the time of placenta formation. These lesions do not show spontaneous regression. Although these two lesions are recognized as neo-vascular lesions, neo-vascular lesions on imaging may represent conditions other than these two lesions (e.g., peritrophoblastic flow, uterine artery pseudoaneurysm, and villous-derived malignancies). Detecting vasculature at the placenta–myometrium interface and classifying vascular diseases according to hemodynamics in the remnant would facilitate the development of specific treatments.

Vascular Reconstruction of a Brachial Artery Aneurysm Proximally to an Arteriovenous Malformation

2019 ◽  
Vol 54 (1) ◽  
pp. 75-79
Author(s):  
Curtis Woodford ◽  
Elizabeth Tai ◽  
Sebastian Mafeld ◽  
Husain A. Al-Mubarak ◽  
Arash Jaberi ◽  
...  
Keyword(s):  
Arteriovenous Malformation ◽  
Radial Artery ◽  
Brachial Artery ◽  
Arteriovenous Malformations ◽  
Femoral Vein ◽  
Artery Aneurysm ◽  
Vascular Reconstruction ◽  
Endovascular Embolization ◽  
Antecubital Fossa ◽  
Interposition Graft

Brachial artery aneurysms and arteriovenous malformations (AVM) are limb-threatening vascular anomalies. This patient presented with a bilobed brachial artery aneurysm in the antecubital fossa proximally to an AVM arising from the dorsal interosseous and ulnar arteries that had been treated with endovascular embolization, leaving the hand solely supplied by the radial artery. The aneurysm continued to increase in size and imaging revealed concomitant thrombus. A femoral vein interposition graft was used to repair the aneurysm, and postoperatively, the patient retained full left arm function.

Indocyanine Green Videoangiography “In Negative”: Definition and Usefulness in Intracranial Dural Arteriovenous Fistulae

2013 ◽  
Vol 73 (suppl_1) ◽  
pp. ons86-ons92 ◽  
Author(s):  
Juan Antonio Julián ◽  
Pablo Miranda Lloret ◽  
Fernando Aparici Robles ◽  
Andrés Beltrán Giner ◽  
Carlos Botella Asunción
Keyword(s):  
Indocyanine Green ◽  
Arteriovenous Fistula ◽  
Arteriovenous Malformations ◽  
Dural Arteriovenous Fistula ◽  
Simple Procedure ◽  
Vascular Pathology ◽  
Digital Subtraction ◽  
Indocyanine Green Videoangiography ◽  
Arteriovenous Fistulae ◽  
Intracranial Dural Arteriovenous Fistulae

Abstract BACKGROUND: Indocyanine green videoangiography (IGV) raises important limitations when we use it in vascular pathology, especially in cases with arterialization of the venous system such as arteriovenous malformations and fistulae. OBJECTIVE: Our objective was to provide a simple procedure that overcomes the limitations of conventional IGV. We define IGV in negative (IGV-IN), so-called because, in its first phase, the vessel to analyze is clipped, and we report 3 cases of intracranial dural arteriovenous fistulae treated with this procedure. METHODS: In 2011, we applied IGV-IN to 3 patients at our center with Borden type III intracranial arteriovenous fistulae. RESULTS: In all 3 cases, IGV-IN enabled both diagnosis and post-dural arteriovenous fistula exclusion control in 1 integrated procedure no longer than 1 minute, requiring only 1 visualization. CONCLUSION: IGV-IN is an improvement over the conventional IGV method and is able to provide more information in a shorter period of time. It is an intuitive and highly visual procedure, and, more importantly, it is reversible. Studies with larger samples are necessary to determine whether IGV-IN can further reduce the need for postoperative digital subtraction angiography.

scholarly journals Cervical intramedullary spinal cavernoma in setting of unresolved myelopathy: A case report

2020 ◽  
Vol 11 ◽  
pp. 176
Author(s):  
Enyinna Nwachuku ◽  
James Duehr ◽  
Scott Kulich ◽  
Daniel Marker ◽  
John Moossy
Keyword(s):  
Magnetic Resonance Images ◽  
Vascular Lesions ◽  
Case Description ◽  
Cavernous Malformations ◽  
Radiographic Findings ◽  
Intramedullary Lesion ◽  
Spinal Cavernoma ◽  
History Of ◽  
Signal Changes ◽  
Spinal Cavernomas

Background: Spinal cavernous malformations are rare, accounting for approximately 5–12% of all spinal cord vascular lesions. Fortunately, improvements in imaging technologies have made it easier to establish the diagnosis of intramedullary spinal cavernomas (ISCs). Case Description: Here, we report the case of a 63-year-old male with an >11-year history of left-sided radiculopathy, ataxia, and quadriparesis. Initially, radiographic findings were interpreted as consistent with spondylotic myelopathy with cord signal changes from the C3-C7 levels. The patient underwent a C3-C7 laminectomy/foraminotomy with instrumentation. It was only after several symptomatic recurrences and repeated magnetic resonance images (MRI) that the diagnosis of a ventrally-located intramedullary lesion, concerning for a cavernoma, at the level C6 was established. Conclusion: Early and repeated enhanced MR studies may be required to correctly establish the diagnosis and determine the optimal surgical management of ISCs.

Endoscopic Resection of Hemorrhaged Third Ventricle Cavernous Malformation: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (2) ◽  
pp. E51-E51
Author(s):  
Giorgio Palandri ◽  
Thomas Sorenson ◽  
Mino Zucchelli ◽  
Nicola Acciarri ◽  
Paolo Mantovani ◽  
...  
Keyword(s):  
Gold Standard ◽  
Intraventricular Hemorrhage ◽  
Cavernous Malformation ◽  
Third Ventricle ◽  
Gross Total Resection ◽  
Vascular Lesions ◽  
Total Resection ◽  
Cavernous Malformations ◽  
The Third

Abstract Cavernous malformations of the third ventricle are uncommon vascular lesions. Evidence suggests that cavernous malformations in this location might have a more aggressive natural history due to their risk of intraventricular hemorrhage and hydrocephalus.1 The gold standard of treatment is considered to be microsurgical gross total resection of the lesion. However, with progressive improvement in endoscopic capabilities, several authors have recently advocated for the role of minimally-invasive neuroendoscopy for resecting intraventricular cavernous malformations.2-4 In this timely intraoperative video, we demonstrate the gross total resection of a third ventricle cavernous malformation that presented with hemorrhage via a right-sided trans-frontal neuroendoscopic approach.

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