Microsurgical Resection of a Callosal Septal Arteriovenous Malformation: 2-Dimensional Operative Video

Abstract

Corpus callosum arteriovenous malformations (AVMs) are rare lesions, accounting for approximately 4% of brain AVMs. 1 Resection of callosal AVMs presents unique challenges because of their deep location; proximity to critical structures, such as the fornices and internal cerebral veins; and often-dense beds of arterial feeders arising from the distal anterior cerebral artery and its branches. [1][2][3][4] This operative video shows complete resection of a complex, high-grade AVM involving the entire corpus callosum of a teenage woman who presented with headache and decreased level of consciousness. Head computed tomography findings included intraventricular hemorrhage; follow-up computed tomography and digital subtraction angiography confirmed a pancallosal AVM, classified as Spetzler-Martin grade IV (size, 2; deep drainage, 1; eloquence, 1) and Lawton-Young grade I (age, 1; bleeding, 0; compactness, 0), with a supplemented grade of 5. Patient consent was obtained for the procedure. After preoperative embolization, a right bifrontal craniotomy and anterior interhemispheric approach were performed. The A2 segment was identified, and the resection was carried posteriorly, sequentially cauterizing and dividing feeders to the nidus within the rostrum, body, and splenium of the corpus. A large thrombosed venous varix was identified between the anterior and posterior segments of the nidus and excised. Dissection was carried down to the vein of Galen, and after disconnection from the final medial posterior choroidal feeder, a gross total AVM resection was achieved. Key educational points include surgical planning and technical pearls for resection of a large, high-grade, pancallosal AVM with particular attention to the interhemispheric approach and stepwise anatomic resection technique.

Commentary: In Situ Occlusion of a Galenic Arteriovenous Malformation in a Young Child: 2-Dimensional Operative Video

“…In this video article, 1 the authors present a case of neonate suffering from congestive heart failure and pulmonary hypertension at birth, which improved on medical treatment. At age 4 weeks, the child developed obstructive hydrocephalus.…”