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. Arteriovenous malformation, Microsurgical resection, Nidus View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy118 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy118 Microsurgical Resection of Ruptured Large Left Temporo-Occipital Arteriovenous Malformation: 3-Dimensional Operative Video Microsurgical Resection of Ruptured Large Left Temporo-Occipital Arteriovenous Malformation: 3-Dimensional Operative Video Close Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. COMMENT This 3-dimensional video depicts the microsurgical resection of a ruptured Spetzler-Martin grade 4 left temporo-occipital AVM following multi-session preoperative embolization. In addition to the temporo-occipital craniotomy, the authors performed a retrosigmoid craniotomy and mastoidectomy in order to release cerebrospinal fluid for brain relaxation and to provide better exposure of the tentorial surface of the AVM. The authors recommend cauterizing small AVM feeders after placing a temporary clip which stops the blood flow in the vessel allowing for adequate coagulation. The concept of coagulating only the smaller veins during the course of the case and leaving the larger draining veins for the end when the AVM is devascularized is also emphasized. The large draining vein in this particular case is sutured allowing for the clip to be removed therefore minimizing artifact in future MRIs. We congratulate the authors for this great result in view of the complexity of this case. A few points worth mentioning nonetheless: in such a case, brain relaxation can also be obtained by placing a lumbar drain. Moreover, we do not see the need of adding a retrosigmoid approach/mastoidectomy since adequate brain relaxation in conjunction with good bony exposure via a temporo-occipital craniotomy alone, should render visualization of the inferior surface of the AVM relatively straightforward. We routinely use non-invasive optimal vessel analysis (NOVA; VasSol Inc, Riverforest, Illinois)/quantitative magnetic resonance angiography to measure cerebral arterial and venous flow at baseline in patients harboring AVMs, and after each subsequent embolization in order to asses and quantify flow reduction in the AVM, and better understand the hemodynamics surrounding the AVM. This method is very useful and can also help the cerebrovascular surgeon make the decision regarding appropriate timing for microsurgical resection after sufficient flow reduction with embolization is achieved; we usually try to achieve at least 50% flow reduction. NOVA will also allow the surgeon to understand changes in flow post AVM resection. Ziad A. Hage Charlotte, North Carolina Copyright © 2018 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Operative Neurosurgery – Oxford University Press
Published: May 18, 2018
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