The deep cerebral veins and their surrounding neural structures were examined in 50 cerebral hemispheres from 25 adult cadavers in which the arteries and veins had been perfused with red and blue silicone, respectively. Special consideration was given to the size and location of drainage of the vein of Galen and its tributaries.
When a surgeon approaches the pineal region, several veins may hamper the access route. From posterior to anterior, these include the following: the superior vermian and the precentral or superior cerebellar veins, which drain into the posteroinferior aspect of the vein of Galen; and the tectal and pineal veins, which drain into its anterosuperior aspect. The internal occipital vein is the main vessel draining into the lateral aspect of the vein of Galen.
It may be joined by the posterior pericallosal vein, and in that case has an extensive territory. To avoid intraoperative venous infarction, it is important to use angiography to determine the venous organization before surgery and to estimate the permeability and size of the branches of the deep venous system. National Center for Biotechnology Information , U.
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Microsurgical anatomy of the great cerebral vein of Galen and its tributaries.
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The Cerebral Veins Albert L. Rhoton, Jr. Oxford Academic. Google Scholar. Cite Citation. Permissions Icon Permissions. Consequently, it is necessary to locate functional areas, particularly the motor area using appropriate approaches during the operation, like electrophysiologic monitoring. For cases with malformations next to motor area or fasciculi pyramidalis, navigation combined with electrophysiologic monitoring can work well, but further locations of language area and visual cortex are still demanded. In our study, 21 Total resection is an effective therapeutic strategy for patients with AVMs, and residual malformations may increase risk of bleeding.
Multimodal navigation can provide detailed information for vascular morphology and location, so with its guidance, the total resection rate can be significantly elevated during microsurgical treatments for patients with AVMs. Intra-operative ICG fluorescein angiography has been applied for 30 years, mainly for rapid evaluating patency of blood vessels in the Department of Neurosurgery The application of FLOW combined with microscope has being increased in recent years.
This approach half-quantitatively analyzes the distribution of transient hemodynamics in surgical region and colors encoding visualization on the basis of ICG fluorescein angiography. It is characterized by establishing vascular color visual image in surgical region, promptly displaying the direction and sequence of blood flow, drawing time-intensity curves and objectively assessing the hemodynamic status in operation area 18 , ICG fluorescein angiography exhibits obvious advantages in microsurgery for AVMs, such as identifying feeding artery and draining vein. After ICG injection through vena cava, feeding artery starts to appear, followed by draining vein.
Accurate blocking of feeding artery is critical for the safety of surgery. Although the main feeding artery is blocked, other vessels may still supply blood for malformations. Step by step, tiny feeding artery is fulgerized along normal brain tissue on the edge of malformations, and draining vein is not blocked until malformations completely removed. We found that ICG was suitable for the identification of angioarchitecture in superficial AVMs, but to totally expose deeper AVMs in operation area under microscope was not easy.
Specifically, the occurrence of postoperative complications, such as bleeding, epilepsy, was not significantly increased after ICG injection. Moreover, the postsurgical hospital stay was significantly shortened among patients accepting ICG fluorescein angiography. However, in our study, only 16 cases received ICG fluorescein angiography.
The relatively small sample size might limit the representativeness of the results, and further investigations with larger sample size will be required to estimate the efficacy and safety of ICG fluorescein angiography in microsurgical treatments for patients with AVMs. AVMs usually leads to spontaneous rupture, so certain preoperative preparations are essential to handle acute bleeding, previous bleeding and chronic symptom. For patients with extensive preoperative intracranial hemorrhage, AVMs might even result in cerebral hernia and coma.
Furthermore, preoperative functional navigation planning was impossible for this condition even if functional areas were involved. If possible, emergency DSA or CTA would be adopted to investigate reasons for bleeding, and accordingly, emergency operation was implemented to remove hematoma while intracranial pressure monitoring was performed, even for patients receiving decompressive craniotomy. Patients with serous nervous dysfunction resulting from acute hemorrhage would recovery well after receiving appropriate and timely treatments. In addition, detailed evaluation of functions would be accomplished before surgical treatment Based on our clinical experiences, patients would benefit from the intra-operative application of multimodal navigation conjunction with electrophysiologic monitoring in microsurgery, especially for hemorrhage ones without severe nervous dysfunction and those with good operation indication.
Besides, positive surgical treatments were proposed for younger patients given their higher cerebral tolerance, whereas follow-up and observations were recommended for older ones with functional areas involved so as to lower the risk of cumulative bleeding 12 , 16 Fig. For patients whose malformations showed intimate relationship with functional configuration in preoperative assessment and those failing to finish preoperative estimation due to long-term chronic weakness caused by hemorrhage, positive surgery might further deteriorate nervous dysfunction, and tereotactic radio surgery or conservative treatment was recommended.
Flow chart for microsurgery management in patients with AVMs according to relevant publications and our experiences. The flow chart included the patients selection, preoperative functional evaluation, and the decision of the extent of surgical resection. In conclusion, microsurgical resection is an effective treatment for patients with cerebral AVM in clinical practice. Moreover, the safety of microsurgery can significantly benefit from guidance approaches, such as functional neural navigation, electrophysiologic monitoring and other advanced technologies like FLOW Ondra, S.
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Safety and efficacy of intraoperative angiography in craniotomies for cerebral aneurysms and arteriovenous malformations: a review of consecutive cases. Neurosurgery 71 , —9 Tong, X. New predictive model for microsurgical outcome of intracranial arteriovenous malformations: study protocol.
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Neurosurg Focus 26 , E9 Stapleton, C. World Neurosurg 83 , —56 Takagi, Y. Evaluation of serial intraoperative surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography in patients with cerebral arteriovenous malformations.
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Neurosurgery 70 , 34—42, discussion 42—3 Sun, G. Intraoperative MRI with integrated functional neuronavigation-guided resection of supratentorial cavernous malformations in eloquent brain areas.
Microsurgical anatomy of the deep venous system of the brain. - PubMed - NCBI
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