This five-minute video reviews the warning signs for arteriovenous malformations, discusses treatment goals for AVMs in the very young, and offers images that illuminate both the condition itself and keys to successful surgical resection.
Hello. My name is Jared Roland. I'm a pediatric neurosurgeon at Benioff Children's Hospital at the University of California, San Francisco. Today I'll be reviewing with you the treatment of an arterial venous malformation or a VM for short in our hybrid angiography operating room. And a VM is a collection of abnormal blood vessels that bypasses the normal capillary system, informs official between arterial and venous cerebral blood vessels. When a VM ruptures, the bleeding that occurs in the brain is referred to as a hemorrhagic stroke. The presenting symptoms could be similar to what is commonly thought of for a scheme IQ stroke but also includes sudden onset, severe headache, alteration of consciousness, seizure, weakness on one side of the face or body, difficulty speaking or understanding speech, visual field cuts and other sudden neurologic deficits. Unfortunately, there is typically some degree of brain injury that is permanently incurred at the time of the hemorrhage. Occasionally, a hemorrhagic stroke causes such severe pressure on the brain that it needs to be treated with an emergent surgery to prevent secondary injury to adjacent brain regions. Reducing secondary injury and preventing future hemorrhage is where surgical resection of a navy M often comes into consideration. I will now walk you through the treatment of a 14 year old girl who presented with acute onset of headache and a sudden alteration of consciousness. Here we see a contrast enhanced memory that demonstrates the small feeding vessels traversing the temporal lobe to UM, or dense collection of abnormal vessels that we refer to as the Knights of the A V M. The night. This is the core of abnormal vessels that make up the A. P M, and the feeding vessels are those that provide its proximal blood supply. The night is does not have a typical transition of artery to arterial to cap Hillary, then drainage into vein UAL and then too vain. Instead, the blood supplied by feeding arteries quickly passes through the A V M with a high rate of flow and out the draining veins much quicker than blood into other parts of the brain. This is referred to as shunting into a draining vein. In this lateral view of an internal carotid artery angiogram, we see contrast flowing into the A V M notice and quickly fills a draining vein. The draining vein appears much earlier in the sequence than any other veins. And while only arteries are visible in other regions of the brain, this early Venus shunting as part of what helps us identify even small a V EMS and more challenging cases, as well as to confirm complete disconnection of the fistula after surgical resection of the notice here we have completed our surgical exposure and can directly see the arteriovenous mixing occurring in the early draining vein. It is critically important to resect the high pressure arterial feeding vessels prior to the draining vein. This is because of the outflow of the A. V M is disconnected prior to its high pressure inflow. The result could be a rupture of the A V M during surgery, making treatment much more difficult to control. Under the operating microscope, we use a combination of micro scissors and bipolar electric lottery to dissect down to the arterial supply and disconnect it first. Once this is accomplished, we complete three section of the remaining itis, which is often a tangle of blood vessels intermingled amongst adjacent brain Perrin coma. As the disconnection occurs, we can confirm the draining vein has evolved from a bright to dark red this color change reassures us that there is no longer arteriovenous mixing from pathologic shunting. We commonly will repeat the I C G while still under the microscope to further ensure no active shunting. However, this is still limited to the basket. Sure that is visible within the line of sight when available, and inter operative angiogram is an excellent told to confirm complete disconnection. The difference is more apparent when the preoperative and interruptive an angiogram are compared side by side. Here we can see the previously identified avian itis and early draining vein are no longer present on the inter operative angiogram. This gives us confidence that we have completed our procedure and so we can close the wound and wake the patient up. At UCSF, we have a unique hybrid operating room where we can perform open surgery, followed by formal catheter angiogram to confirm complete resection. We can obtain this information in the middle of surgery even before closing the wound. This unique hybrid, or angio suite, is highly advantageous for achieving the best results. With the lowest rate of complication and fewest invasive procedures, Pediatric Avie EMS have a nontrivial rate of recurrence, which is unique in comparison to a VM is typically seen in the adult population. Because of this, they often need surveillance imaging for some period of time after treatment and small a VMS with compact notice and in areas of the brain surgically accessible, such as the case demonstrated here, we often can achieve a high cure rate for a lesion that otherwise has a lifetime risk of hemorrhage, particularly in a pediatric patient with a long life expectancy. Pediatric a. VM, our common cause of spontaneous intracranial hemorrhage and require complex multi disciplinary treatment between neurosurgeons, neuro, interventional radiologists, neurologists, Visy interests and many others. No to a VMS are identical, and the nuances to treatment decisions are complex and often require detailed discussions to consider all of the treatment options. I hope that this case presentation helps to familiarize you with some of the basic concepts, as well as a representative surgical treatment of a pediatric brain arteriovenous malformation. Thank you
