Removal of superior vermian arteriovenous malformation through the occipital transtentorial approach

Acute surgery for a case of superior vermian arteriovenous malformation producing raised venous pressure coexisting with basilar-superior cerebellar artery aneurysm presenting subarachnoid hemorrhage; Case report

“…Although there are various opinions regarding the patient’s position, we prefer to have the affected sided down, with the patient in lateral recumbency, to allow natural and gentle retraction of the occipital lobe under gravity and to prevent postoperative occipital lobe contusion causing hemianopsia. [ 2 , 16 , 19 ] It is also important to prevent occipital lobe damage due to contact between the dural edge and the occipital lobe by not expanding the range of the dural incision to the outside. In this approach, bleeding from the tentorial sinus may limit posterior extension of the tentorial incision, resulting in difficulty processing the posterior feeders from the PICA, or more external SCA or anterior inferior cerebellar artery feeders.…”

“…In addition, if the AVM body greatly extends contralaterally beyond the midline or exhibits caudal dilatation to the cerebellar tonsils or the fourth ventricle, using only this approach may limit exposure. [ 3 , 16 , 19 ] In such cases, it is necessary to consider combined approaches and concomitant preoperative feeder embolization. [ 1 , 10 ]…”