Summary Seven AVMs - Surgical Master Class Part 1 - YouTube (Youtube) youtu.be
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Speaker 0 This video is part 1 of a lecture series on brain Ab surgery techniques or 7 (AVMs) surgical master class. In this video, we will discuss Av taxonomy the basic resection steps for all Av and the concept of the Av box, This slide summarizes my surgical experience with brain (AVMs) over my career. And you can see that I've managed to operate on many of these lesions. I've overtake my mentor, dr Sp in total brain Removed, and it's worth noting that if you compare my individual surgical series with all of the surgical volume in the ar trial, minus 50 times larger than that. This just gives you a bit of a perspective on what you're about to hear.
Speaker 0 Many of my thoughts from this talk (AVMs) been summarized. In my book, 7 Av. And I wrote this book because I wanted to try and make sense of Av surgery when I ended my training, I didn't feel as though I had figured it out and felt that a couple of things would be helpful. First would be a taxonomy for Av that transform the wide variety of lesions into some recognizable system of subtype. That way, when you come upon 1 particular subtype, then you wouldn't have to rethink the whole thing, but you could simply apply learning from each subtype type to your individual case.
Speaker 0 Next, I wanted to conceptualize the surgical steps because I felt that breaking surgery down into specific steps in a very granular way was a real helpful learning tool. Finally, I felt that we needed to improve our technique and our results, particularly in the Ar and post ar era where, We are under such scrutiny to be high performers. I like Metaphors and the metaphor I chose for this book was war. When I think about Av resection, I think of the neuro as a soldier, the cerebral vascular anatomy is our battlefield. The specific (AVMs) subtype as the enemy and the resection steps as our battle plan.
Speaker 0 It's a very mil view, but I think it's very valuable. First is the issue of taxonomy. This slide is meant to depict the incredible array of different types of lesions. No way Vm is identical to the next. And so it's very easy to say that you can't categorize or have a taxonomy that's applicable to this incredible spectrum of disease.
Speaker 0 If you think beyond that you can really break Av down into 7 types and additional subgroup of sub types. The 7 types have to do with the location in the brain. The 7 types are frontal, deep, p, period ventricular, temporal, brainstem and ce. The subtype have to do with the surface within that type that the Av is based upon. And those different surfaces can be lateral, media, para median basal, anterior lateral posterior, what have you.
Speaker 0 It really depends on the region you're in, but It's this combination of type and subtype that allows you to really categorize or classify. And it's very much like the way we think of animals. In the animal kingdom when we classify them according to their ph and species and genus. So as an example, these are different frontal (AVMs). You have a frontal Av that's on the lateral surface.
Speaker 0 You can have another 1 that's on the media surface. You can have 1 that's on the basal surface, and finally 1 in the Sylvia surface. There's also this additional 1, what I call the Para median, which lies at the confluence of the lateral and the media right along the sag sinus. So these are the 5 subtype within that frontal type of Av. Another example is the Ce (AVMs), the Ce has 3 surfaces, The sub tent and patrol surface.
Speaker 0 And so each of these 3 has a subtype but then there are Vi and tons Ab giving a total of 5 different Av subtype in the ce. The next is the breakdown of the res steps, 5 ranging from exposure to sub dissection to draining vein to feeding arteries, then going into the different phases of resection with peel dissection, per dissection, and a pen dissection, and then finally Av resection. Just as an example, step 4 is figuring out the feeding arteries. This slide shows that there are many different types of feeding arteries. There's the...
Speaker 0 Terminal feeding artery that goes right into the Av and ends in the Av. This is an artery that you can simply include there's the transit artery that feeds the Av through branches as it courses through or next to the Av, but also continues dis to supply normal brain. So this is an artery that needs to be managed differently from the terminal feeder. Then there are deep per perforation arteries that feed usually the white matter portions of the Av and there are cor feeder that come up through the ventricle. Lastly, there are by arteries that appeared to feed an Av because they're near, but they give no branches and need to be carefully protected.
Speaker 0 These distinctions are important because once you identify these arteries according to these definitions, then you treat them differently the. Transit artery is dissect from distal to proxima. That way it ensures that you save the distal outflow and allows you to then work approximately taking all of the branches that then feed the (AVMs). The dissection steps really can be summarized in what I call the battle plans, these allow you to take those 8 steps, super them on the anatomy of the Av, which is diagram here as a cube. With arrows representing the feeding arteries and the draining veins, and then you can see these different steps of the resection graphically as you go through.
Speaker 0 This is just an example of the lateral frontal (AVMs) that's fed by fears off of the M 2 segment of the middle cerebral artery. Draining into deep and superficial Sylvia veins and how by splitting the Sylvia fisher to get to those feeding arteries and working from below you can nicely d the Av early and proceed with the resection. I wanted to focus on what I call master concepts. And these are some of the more sophisticated ideas that go beyond these basics. I think this idea of the Av as a cube is important.
Speaker 0 The cube is shown here in this illustration with the arterial feeder represented as red arrows and the draining veins there's blue arrows. And no (AVMs) is in the shape of a cube, but it reduces these complex shapes into 6 sides. And then you can regional the anatomy to the different size, and it helps you anticipate where you'll find your anatomy and also where you'll find the eli that you need to be careful to protect. The Av box gets you thinking about the feeding arteries, the draining vein and the eli. The feeding arteriovenous draining veins are diagram with those red and blue arrows.
Speaker 0 The el is diagram with these color maps of critical function, and the Av box is a way to really get all of these different elements organized, conceptually as you begin you're thinking about your surgical plan. The other important idea about the box is that it segregate the different dissection phases. The E when it's thought of as having 6 sides, it will have a superficial or peel side it will have 4 per sides that dig into the brain tissue. And finally, it'll have an append side, which doesn't necessarily go down to the ventricle, but it gets down to the deep portion of the Av or the tip of the cone. These different phases of dissection correlate to different size of that cube.