Resection of Right Frontal Arteriovenous Malformation: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (1) ◽  
pp. 111-111
Author(s):  
William T Couldwell
Keyword(s):  
Arteriovenous Malformation ◽  
Venous Drainage ◽  
Complete Resection ◽  
Institutional Review Board ◽  
3 Dimensional ◽  
Bone Removal ◽  
Institutional Review ◽  
Brain Interface ◽  
Grade Ii ◽  
The Right

Abstract The video demonstrates resection of a Grade II Spetzler-Martin unruptured, medium-sized arteriovenous malformation (AVM). A young woman presented with headaches and seizures. The right frontal lesion measured 4.5 cm in largest dimension and had superficial venous drainage. Partial Onyx embolization, primarily of the anterior cerebral feeding arteries, was performed. Bone removal for exposure allowed identification of indentation from the large superficial draining vein. The video demonstrates careful microsurgical dissection on the AVM/brain interface, with selective interruption of feeding arteries circumferentially. The lesion was removed after ligation of the large superficial draining vein. Postoperative day 1 and 1-yr angiography demonstrated complete resection. The patient's symptoms abated after resection. This case is presented with a waiver of informed consent as per the Institutional Review Board.

scholarly journals Grade 4 Temporal Arteriovenous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E36-E37
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Informed Consent ◽  
Arteriovenous Malformations ◽  
Video Recording ◽  
Venous Drainage ◽  
Complete Resection ◽  
Elevated Risk ◽  
Institutional Review Board ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Martin Grade

Abstract The 2% to 4% annual rupture rate for arteriovenous malformations (AVMs) must be weighed against the risk of intervention during surgery within an eloquent brain region. Following a hemorrhage event, AVMs that were initially considered to be nonoperative or unfavorable for surgical resection can be intervened on to avoid the significantly elevated risk of rehemorrhage. This patient had a dominant temporal lobe Spetzler–Martin grade 4 AVM with deep venous drainage, representing a significant surgical challenge. The arachnoid plane microdissection was performed using microscissors but was tenuous, and it was necessary to define the draining vein and adjacent feeding arteries. This video demonstrates the major principles of AVM resection during the circumdissection and disconnection of the nidus. The postoperative angiography demonstrated complete resection. 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.

Intraoperative Ultrasound Navigation with Doppler Function to Guide Arteriovenous Malformation Resection: 3-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E162-E163
Author(s):  
Marcos Dellaretti ◽  
Daniel Espindola Ronconi
Keyword(s):  
Arteriovenous Malformation ◽  
Doppler Ultrasound ◽  
Superior Sagittal Sinus ◽  
Intraoperative Ultrasound ◽  
Complete Resection ◽  
Sensory Cortex ◽  
Cortical Mapping ◽  
3 Dimensional ◽  
Sagittal Sinus ◽  
The Right

Abstract Intraoperative ultrasound navigation was initially introduced in the neurosurgical field for brain tumor surgery and was then extended to arteriovenous malformation surgery with good success. This tool provides real-time intraoperative images.1 Moreover, Doppler ultrasound permits early identification of feeding arteries and supplies the surgeon with a global impression of the flow dynamics.2 A further use of doppler is to check for residual nidus. Other advantages are the capacity to identify intracerebral hemorrhage.2 In this video, we demonstrate the case of a 15-yr-old patient who presented intracranial hemorrhage. Magnetic resonance imaging revealed the presence of left frontoparietal hematoma associated with an image suggestive of cerebral arteriovenous malformation (AVM). Arteriography confirmed the diagnosis of AVM fed by branches of the anterior cerebral and superficial drainage for the superior sagittal sinus. The patient was placed in dorsal decubitus with his head turned to the right and a left parietal-frontal craniotomy was performed. After the dura mater was opened, cortical mapping was performed to locate the motor and sensory cortex. After the mapping, ultrasound with doppler was performed to locate the AVM and the hematoma and determine its relation to the motor and sensory cortex. At the end of the surgery, doppler ultrasound was used again to ensure complete resection of the AVM. Intraoperative Ultrasound navigation with doppler is an inexpensive technology that can be used in the treatment of AVMs, especially in the subcortex, as it assists in locating the nidus and confirms its complete resection.

scholarly journals Cervical 3 to Cervical 6 Laminectomy for Arteriovenous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E200-E200
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Arteriovenous Malformation ◽  
Surgical Resection ◽  
Video Recording ◽  
Institutional Review Board ◽  
Digital Subtraction ◽  
Pia Mater ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Complete Obliteration ◽  
System 1

Abstract According to the Spetzler spinal cord classification system,1 this patient had an extradural-intradural arteriovenous malformation (AVM), also known as a type III or juvenile AVM. The patient underwent a surgical resection of the lesion via a cervical 3 to cervical 6 laminoplasty. Direct observation confirmed intra- and extramedullary components. During the surgical resection, an attempt was made to avoid transgressing the pia mater. Therefore, the traversing vessels were interrupted during the circumdissection. The nidus was removed, and postprocedural digital subtraction angiography confirmed complete obliteration. 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 Anterior Interhemispheric Transcallosal Approach for Thalamic Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (6) ◽  
pp. E240-E241
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cavernous Malformation ◽  
Third Ventricle ◽  
Video Recording ◽  
Complete Resection ◽  
Institutional Review Board ◽  
Transcallosal Approach ◽  
The Third ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Surgical Field

Abstract This patient had a large left ventral thalamic cavernous malformation abutting the third ventricle with evidence of recent hemorrhage. The patient was placed supine with the head in the horizontal position with the dependent hemisphere down to permit use of the anterior interhemispheric transcallosal approach. The lateral ventricle is entered, and the septum pellucidum is opened to prevent it from obstructing the surgical field. The deep cavernous malformation is located with stereotactic neuronavigation and removed piecemeal with the aid of lighted suckers and bipolars. Surgical visualization and postoperative imaging demonstrate a complete resection of the lesion, and the patient remained neurologically stable postoperatively. 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 Modified Orbitozygomatic Craniotomy for Previously Coiled Giant Basilar Apex Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E199-E199
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Institutional Review Board ◽  
Anterior Circulation ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Orbitozygomatic Approach ◽  
Clip Application ◽  
Complicating Factors ◽  
The Right ◽  
Significant Size

Abstract Basilar apex aneurysms are generally preferentially managed with endovascular intervention; however, these lesions can demonstrate refractory persistence despite this treatment and, in such cases, must be managed microsurgically. Successful navigation to and manipulation of the basilar apex through the orbitozygomatic approach requires an intricate understanding of the cerebrovascular microanatomy and arachnoid planes within interpeduncular fossa and comfort with use of the operating microscope for the long surgical trajectory to the basilar apex. This patient had a multiply recurrent basilar apex aneurysm; 3 previous coil embolization attempts had been made without successful aneurysm obliteration. This case presented multiple complicating factors, including the presence of a large coil mass and the significant size of the basilar apex lesion. An Allcock test was performed to determine the collateralization across the posterior communicating arteries, and no posterior communicating arteries were visualized, which suggested isolation of the posterior and anterior circulation. A fenestrated clip was utilized from the right side to occlude the base of the aneurysm. Single-clip application was not impeded by the coil mass. Postoperative angiography demonstrated complete occlusion of the aneurysm. 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 Thoracic 11-Lumbar 1 Laminoplasty for Resection of Conus Arteriovenous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E7-E7
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Arteriovenous Malformation ◽  
Video Recording ◽  
Venous Drainage ◽  
Conus Medullaris ◽  
Imaging Evaluation ◽  
Drainage Patterns ◽  
Institutional Review ◽  
Before And After ◽  
Spinal Arteriovenous Malformations ◽  
Multiple Feeding

Abstract Conus medullaris spinal arteriovenous malformations are uniquely classified by the Spetzler classification. They possess a glomus (type II) nidus in either or both the intra- and extramedullary compartments, with multiple feeding arteries and niduses resulting in complex venous drainage patterns. These characteristics make resection of these lesions challenging, and these lesions are associated with a high risk for recurrence. This patient presented with a subarachnoid hemorrhage, and thorough imaging evaluation revealed a conus arteriovenous malformation. The patient underwent thoracic 11 to lumbar 1 laminoplasty for resection of the lesion. The arteriovenous malformation was circumdissected off the conus and lumbosacral nerve roots using sharp dissection and bipolar forceps. It was visualized both before and after resection with indocyanine green fluoroscopy. The patient tolerated the procedure well, and postoperative angiography demonstrated complete resection. 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.

Making the case for completion bonuses in clinical trials

2018 ◽  
Vol 16 (2) ◽  
pp. 176-182 ◽  
Author(s):  
Emily A Largent ◽  
Holly Fernandez Lynch
Keyword(s):  
Clinical Trials ◽  
Financial Incentives ◽  
Institutional Review Board ◽  
Study Endpoint ◽  
Ethical Problems ◽  
Research Participants ◽  
Institutional Review ◽  
The Right ◽  
Incentive Payments

Attrition is a serious problem in many clinical trials. The practice of offering completion bonuses—financial incentives offered to participants on the condition that they remain in a trial until they reach a prespecified study endpoint—is one means of addressing attrition. Despite their practical appeal, however, completion bonuses remain ethically controversial due to concern that they will coerce or unduly influence participants to not exercise their right to withdraw from a trial. Although this interaction with the right to withdraw does render completion bonuses conceptually distinct from other incentive payments offered to research participants, we argue here that completion bonuses are never coercive and, in the context of effective institutional review board oversight, are unlikely to be unduly influential. Nonetheless, because completion bonuses may in some cases still encourage unreasonable continued participation in a study, additional safeguards are appropriate. Rejecting completion bonuses entirely is, however, unnecessary and would problematically fail to address the significant ethical problems associated with participant attrition.

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.

scholarly journals Reversible pulmonary hypertension and high-output heart failure triggered by pregnancy in a patient with congenital arteriovenous malformation: A case report

2018 ◽  
Vol 12 (2) ◽  
pp. 97-99
Author(s):  
Héctor Saavedra ◽  
Celina Toncel ◽  
Vanessa Delgado ◽  
Orlando Borré ◽  
José Rojas-Suárez
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Arteriovenous Malformation ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
High Output Heart Failure ◽  
Congenital Arteriovenous Malformation ◽  
The Right ◽  
High Index Of Suspicion ◽  
High Output

Background Arteriovenous malformations rarely cause congestive heart failure. Pregnancy may in theory trigger heart failure associated with congenital arteriovenous malformations leading to secondary pulmonary hypertension, but no cases have been reported proving that condition. Methods and results We report a 23-year-old pregnant woman at 36 + 5 weeks of gestation requiring urgent medical care because of shortness of breath. High-output heart failure was suspected, and a congenital arteriovenous malformation on the right scapular region was considered as the possible origin. The patient required urgent caesarean delivery because of ongoing cardiac failure, which improved soon after delivery. Postpartum angiography of the right subclavian artery revealed an arteriovenous malformation on the deltoid region with venous drainage through the subclavian vein and increased flow to the superior cava vein and right atrium. Conclusion A high index of suspicion of arteriovenous malformations should be maintained in pregnant women with cutaneous vascular malformation-like lesions, if symptoms of heart failure are present.

scholarly journals The paramedian supracerebellar-transtentorial approach to remove a posterior fusiform gyrus arteriovenous malformation

2017 ◽  
Vol 43 (videosuppl1) ◽  
pp. V7 ◽  
Author(s):  
Mehmet Volkan Harput ◽  
Uğur Türe
Keyword(s):  
Arteriovenous Malformation ◽  
Cerebral Angiography ◽  
Posterior Cerebral Artery ◽  
Venous Drainage ◽  
Transverse Sinus ◽  
Fusiform Gyrus ◽  
Posterior Portion ◽  
Postoperative Mri ◽  
The Right ◽  
Transtentorial Approach

This is the case of a 14-year-old female who presented with headache and seizures. Cranial magnetic resonance imaging revealed an arteriovenous malformation (AVM) located at the posterior portion of the right-sided fusiform gyrus. Cerebral angiography showed that the AVM was fed mainly by branches from the inferior temporal trunk of the posterior cerebral artery. The main venous drainage was to the right transverse sinus through the tentorial vein. The AVM was totally excised through the paramedian supracerebellar-transtentorial approach with the patient in a semisitting position. Postoperative MRI and cerebral angiography confirmed the total resection. The patient was discharged on the 5th postoperative day without neurological deficit.The video can be found here: https://youtu.be/QPrUl8AP7G8.

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