Name:
10.3171/2023.10.FOCVID23114
Description:
10.3171/2023.10.FOCVID23114
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/e412c6e5-8436-4acd-9f20-ff7f0977cbfb/videoscrubberimages/Scrubber_160.jpg
Duration:
T00H07M44S
Embed URL:
https://stream.cadmore.media/player/e412c6e5-8436-4acd-9f20-ff7f0977cbfb
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/e412c6e5-8436-4acd-9f20-ff7f0977cbfb/9. 23-114.mp4?sv=2019-02-02&sr=c&sig=6oQHQpwyXFLv%2FhNjvYDpPrbBemwUa1v%2BpiyGrEccPME%3D&st=2024-12-26T23%3A47%3A46Z&se=2024-12-27T01%3A52%3A46Z&sp=r
Upload Date:
2023-11-30T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SERENA TOLA: A 46-year-old man with established diagnosis of brain AVM presented to the emergency department with symptoms of sudden hemiparesis and a rapid neurological deterioration to GCS4, requiring orotracheal intubation. The CT scan revealed the right frontal parietal hemorrhage with ventricular hemorrhage, as well as signs of the former endovascular treatments. He underwent emergency external ventricular drainage with ICP microsensor.
SERENA TOLA: DSA showed Spetzler-Martin grade III right frontoinsular AVM. Feeders came from the right MCA with a deep insular feeder as well. A single superficial venous drainage towards the Sylvian middle cerebral vein was present. Treatment strategy consisted of a preliminary embolization of the deepest feeders, followed by surgical excision and hematoma evacuation. DSA and CT angio performed after the preoperative embolization showed nidus reduction and slowdown of the venous drainage.
SERENA TOLA: Surgery was performed under exoscope view. Exoscope view was preferred to gather a more immersive two-dimensional intraoperative view, thus allowing the surgical team to share exactly the same view of the surgeon and bringing to a prompter interaction. Moreover, the possibility to watch the ICG video angiography live was found to be more informative and faster than the surgery progression, particularly when repeated ICG may be required.
SERENA TOLA: Patient was in supine position, with the head turned toward the left of 45 degrees. The head was fixed in a metal clamp. A frontotemporal incision and craniotomy were performed. Neuronavigation and intraoperative neurophysiological monitoring for somatosensory evoked potential and motor evoked potential were also employed. Initial dural incision was tailored with neuronavigation away from the AVM's nidus to obtain cerebral release by partially evacuating the cerebral hemorrhage.
SERENA TOLA: ICG videoangiography after dural opening showed a dark area on the frontal lobe, where signs of the former embolization were detectable, thus further aiding the AVM's nidus localization. ICG also clearly showed the arterialized draining vein with anterograde flow towards the superficial middle cerebral vein. Nidus dissection started on the most anterior part of the AVM toward a small corticectomy and proceeded circumferentially to completely isolate the most superficial portion of the nidus.
SERENA TOLA: The posterior aspect of the nidus disclosed intracerebral hematoma. Advancing in the dissection of the deeper portion of the AVM, several feeders were cauterized starting from the smaller and shifting to the greater ones. Former embolized vessels were also isolated and cut.
SERENA TOLA: The draining vein side of the nidus was also isolated. The hematoma evacuation was almost completed, thus facilitating the final nidus delimitation.
SERENA TOLA: Exoscope allowed to repeatedly change the angle of view during nidus dissection without relevant changes in the surgeon position, thus resulting in enhanced ergonomics for both the surgeon and assistant. Furthermore, the compact camera frame preserved from hampering both the field of view and surgical movements. After completing dissection, the nidus was finally pulled out and an ICG videoangiography was performed before closing the venous drainage.
SERENA TOLA: ICG shows some residual aterialized flux in the vein. Thus a tiny portion of the nidus strictly adherent to the drainage vein was dissected and excluded. The vein was closed and the AVM was removed.
SERENA TOLA: Since some residual vein aterialization is an indirect expression of nidal remnants, a last ICG angiography was performed after AVM's removal. Even this ICG showed persistent vein aterialization. Thus, we further dissected a more distal part of the drainage unveiling a tiny artery resulting in arteriovenous fistula.
SERENA TOLA: Exoscope allowed to perform an ICG videoangiography even at high magnification without relevant losing of image definition. ICG confirmed the presence of the arteriovenous fistula, which was then further dissected along with a small nidus remnant adherent to the hidden wall of the vein, which was then removed.
SERENA TOLA: No more vein aterialization was detectable at the following ICG videoangiography. Exoscope provide for a wide range of motion and field of view. Learning curve isn't steep and surgical movements adaptivity takes advantage mostly from operating on superficial lesions. As a consequence, surgical movements (even clip positioning) were not significantly affected during surgery.
SERENA TOLA: Postoperative DSA showed complete removal of the AVM with no residual shunts. The patient partially recovered and he was discharged to rehabilitation with a modified Rankin score of 4.
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
