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Rami Almefty1, Walid Ibn Essayed2, Ossama Al-Mefty2
  1. Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Philadelphia, United States,
  2. Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, United States.

Correspondence Address:
Ossama Al-Mefty, MD, Director of Skull Base Surgery, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.

DOI:10.25259/SNI_217_2022

Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Rami Almefty1, Walid Ibn Essayed2, Ossama Al-Mefty2. Multimodality resection of Oliveira Type IIIC* cerebellar AVM: A distinct entity. 22-Apr-2022;13:163

How to cite this URL: Rami Almefty1, Walid Ibn Essayed2, Ossama Al-Mefty2. Multimodality resection of Oliveira Type IIIC* cerebellar AVM: A distinct entity. 22-Apr-2022;13:163. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=11559

Date of Submission
02-Mar-2022

Date of Acceptance
01-Apr-2022

Date of Web Publication
22-Apr-2022

Abstract

Background: Posterior fossa AVMs constitute about 10% of AVMs and are associated with a higher rate of hemorrhage and increased morbidity and mortality rates necessitating treatment with rare exception. Cerebellar AVMs differ markedly from their supratentorial counterparts in that there are no perforating vessels involvement, drainage into the deep cerebral venous system, or presence of eloquent functional area except for the dentate nucleus. While Yaşargil has classified cerebellar AVMs into seven subtypes according to their location, de Oliveira et al. have classified them using a more impactful grading system based on the size, location, and involvement of the dentate nucleus with the highest risk being III (size over 4 cm) C (mixed superficial and deep location) * (dentate involvement). In this extensive AVM with multiple arterial feeders from the SCA, AICA, and PICAs, preoperative embolization facilitates the safe surgical removal.

Case Description: We present the case of resection of de Oliveira et al. IIIC* cerebellar AVM highlighting the tenets of preoperative embolization, wide surgical exposure with an extended retrosigmoid approach, arachnoidal dissection of the SAC, AICA, and PICA feeders, parenchymal dissection with preservation of the dentate nucleus, and preservation of venous drainage until complete disconnection. The patient consented to surgery after presenting with hemorrhage and developed hydrocephalus and CSF leak, managed successfully.

Conclusion: de Oliveira et al. classification is highly impactful in grading posterior fossa AVMs.

Keywords: Arteriovenous malformation, AVM embolization, Cerebellum, Microsurgery, Retrosigmoid craniotomy

Video 1

Annotations[1-5]

00:14 – Preamble

01:03 – Clinical presentation

01:09 – Neuroimaging

01:40 – Embolization

02:38 – Surgical setup

02:57 – Key surgical steps

03:46 – PICA

03:58 – Superficial draining veins

06:20 – Draining vein clipping

07:51 – SCA

09:23 – Outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Videos available on:

https://doi.org/10.25259/SNI_217_2022

References

1. Almeida JP, Yamaki V, Neto MR, Neto FC, Rhoton AJ, Oliveira E, Dumont AS, Sheehan JP, Lanzino G.editors. Surgical treatment of cerebellar arteriovenous malformations. Brain Arteriovenous Malformations and Arteriovenous Fistulas. New York: Thieme; 2018. p.

2. Arnaout OM, Gross BA, Eddleman CS, Bendok BR, Getch CC, Batjer HH. Posterior fossa arteriovenous malformations. Neurosurg Focus. 2009. 26: E12

3. Batjer H, Samson D. Arteriovenous malformations of the posterior fossa. Clinical presentation, diagnostic evaluation, and surgical treatment. J Neurosurg. 1986. 64: 849-56

4. de Oliveira E, Tedeschi H, Raso J. Multidisciplinary approach to arteriovenous malformations. Neurol Med Chir (Tokyo). 1998. 38: 177-85

5. Yaşargil MG, Teddy PJ, Valavanis A, Duvernoy HM.editors. AVM of the Brain. Stuttgart, New York: Thieme; 1987. p.

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