Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Arteriovenous Malformation (AVM) Resection

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [left/right] [location] AVM (Spetzler-Martin grade [I-V]) presenting with [hemorrhage / seizures / headache / incidental] planned for craniotomy for microsurgical resection [± preoperative embolization].

Figures, Imaging & Video

🎥 Operative videos & resources

🧭 Operative approach: Pterional craniotomy — detailed corridor setup, step-by-step technique & figures

Copyrighted operative figures/videos are linked, not copied. Embedded figures below are public-domain or CC-BY; see media-sources.md and CREDITS.md.

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Arteriovenous Malformation Resection — Figure 1 Figure 1. Gross findings and temporal bone computed tomographic angiography findings on the ear of a 60 year-old man, as recorded in the emergency room: (A) the patient presented with a swollen… Source: Arteriovenous malformation of the external ear: a clinical assessment with a scoping review of the literature☆ — Brazilian Journal of Otorhinolaryngology 2017; CC BY.

Arteriovenous Malformation Resection — Figure 2 Figure 2. Preoperative therapeutic embolization using transfemoral cerebral angiography and gross ear findings 3 days after embolization: (A) transfemoral cerebral angiography revealed large… Source: Arteriovenous malformation of the external ear: a clinical assessment with a scoping review of the literature☆ — Brazilian Journal of Otorhinolaryngology 2017; CC BY.

Arteriovenous Malformation Resection — Figure 3 Figure 3. Gross ear findings at 2 weeks after embolization and total excision of the arteriovenous malformation. (A) Two weeks after transarterial embolization, the boundary of the necrotic skin… Source: Arteriovenous malformation of the external ear: a clinical assessment with a scoping review of the literature☆ — Brazilian Journal of Otorhinolaryngology 2017; CC BY.

Arteriovenous Malformation Resection — Fig. 1 Fig. 1. Findings of upper gastrointestinal endoscopy. Upper gastrointestinal endoscopy revealed a large ulcer at the duodenal bulb. Source: Efficacy of Arterial Embolization prior to Pancreaticoduodenectomy for Pancreatic Arteriovenous Malformation: A Case Report — Surgical Case Reports 2025; CC BY.

Arteriovenous Malformation Resection — Fig. 2 Fig. 2. Findings of computed tomography (CT). (A) Non-enhanced CT showed the presence of intrahepatic reticulated calcification, indicating the presence of Schistosomiasis japonica. (B)… Source: Efficacy of Arterial Embolization prior to Pancreaticoduodenectomy for Pancreatic Arteriovenous Malformation: A Case Report — Surgical Case Reports 2025; CC BY.

Arteriovenous Malformation Resection — Fig. 3 Fig. 3. Findings of angiography. (A) Angiography of the celiac axis showed a markedly proliferative vascular network at the pancreatic head (arrowhead) via the gastroduodenal artery and early… Source: Efficacy of Arterial Embolization prior to Pancreaticoduodenectomy for Pancreatic Arteriovenous Malformation: A Case Report — Surgical Case Reports 2025; CC BY.

Arteriovenous Malformation Resection — Fig. 4 Fig. 4. Intraoperative findings. The intraoperative findings did not demonstrate the impact of arterial embolization on the pancreatic parenchyma.GDA, gastroduodenal artery; MPV, main portal… Source: Efficacy of Arterial Embolization prior to Pancreaticoduodenectomy for Pancreatic Arteriovenous Malformation: A Case Report — Surgical Case Reports 2025; CC BY.

Arteriovenous Malformation Resection — Fig. 5 Fig. 5. Pathological findings of resected specimens (hematoxylin and eosin staining). (A) Dilated vessels of unequal size were found in the pancreatic parenchyma, consistent with the finding of… Source: Efficacy of Arterial Embolization prior to Pancreaticoduodenectomy for Pancreatic Arteriovenous Malformation: A Case Report — Surgical Case Reports 2025; CC BY.

Arteriovenous Malformation Resection — Fig. 1 Fig. 1. a Physical examination showed grade 3 left varicocele. b Computed tomography showed early enhanced dilated renal vein (blue arrow) and irregular lesion in the upper pole of left kidney,… Source: Varicocele due to renal arteriovenous malformation mimicking a renal tumor: a case report — Journal of Medical Case Reports 2018; CC BY.

History of Present Illness

Imaging Review

MRI/MRA

DSA (gold standard)

Navigation / Functional

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Preoperative Embolization

Position

Microsurgical Principles (Spetzler/Lawton)

  1. Wide craniotomy — expose nidus plus margin
  2. Identify the draining vein(s) — PRESERVE until the end (premature venous occlusion → nidus engorgement and rupture)
  3. Circumferential dissection around the nidus
  4. Feeding artery control first — coagulate/clip arterial feeders progressively, working around the nidus
  5. Stay on the nidus — dissect in the gliotic plane immediately around the nidus (avoid entering nidus → bleeding; avoid straying into normal brain → deficit)
  6. Deep feeders last — these are thin-walled, fragile, hard to coagulate (“AVM feeders from hell”); may need clips, careful bipolar, hemostatic agents
  7. Take the draining vein LAST — only after all arterial supply controlled; vein should become dark/less pulsatile when arterial feeders are eliminated
  8. Deliver nidus
  9. Meticulous hemostasis — inspect resection bed; “normal perfusion pressure breakthrough” risk
  10. ICG / intraoperative angiography — confirm no residual nidus

Critical Anatomy & Structures at Risk

  1. Draining vein(s) — preserve until arterial supply controlled
  2. Deep perforating feeders — fragile, dangerous bleeding source
  3. Eloquent cortex / white matter tracts — depending on location
  4. En passage vessels — arteries that supply both nidus and normal brain (preserve the normal branch)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Hemorrhage — major risk; preserve draining vein until end
  2. Normal perfusion pressure breakthrough (NPPB) — post-resection hyperemia/edema/hemorrhage in surrounding brain; strict BP control
  3. Residual nidus — intraoperative angiography to confirm complete resection
  4. Neurological deficit — eloquent location, perforator injury
  5. Seizures

Operative Note Template

Preoperative Diagnosis: [Left/Right] [location] arteriovenous malformation, Spetzler-Martin grade [__] [ruptured/unruptured]

Postoperative Diagnosis: Same

Procedure: [Left/Right] [location] craniotomy for microsurgical resection of AVM [following preoperative embolization]

Surgeon / Assistant: Anesthesia: General endotracheal EBL / Fluids / Blood products: [4 units crossmatched, cell saver] Adjuncts: Neuronavigation, ICG videoangiography, intraoperative/postoperative DSA Monitoring: SSEP / MEP [/ mapping if eloquent] — stable Complications: None

Indications: [Age]yo [M/F] with a [ruptured/symptomatic] [location] AVM (SM grade [__]). After [staged preoperative embolization and] discussion of risks/benefits/alternatives (including radiosurgery and observation), microsurgical resection was undertaken.

Description of Procedure: After consent and time-out, general anesthesia was induced with arterial/central access, crossmatched blood and cell saver available, and neuromonitoring established. The head was fixed in Mayfield and positioned with the lesion uppermost. A wide [location] craniotomy was performed — larger than the nidus to expose all feeders and draining veins — and the dura opened.

Under the microscope, the nidus and its major draining vein(s) were identified; the draining vein was preserved and protected throughout. Circumferential dissection was carried out in the gliotic plane immediately around the nidus, progressively coagulating and dividing arterial feeders while staying on the nidus and sparing en-passage vessels. The deep, thin-walled feeders were controlled with micro-clips and careful bipolar. Only after all arterial supply was eliminated — confirmed by the draining vein becoming dark and less pulsatile — was the draining vein coagulated and divided last, and the nidus delivered en bloc.

The resection bed was inspected and meticulous hemostasis obtained under controlled normotension. Intraoperative angiography (ICG ± catheter DSA) confirmed no residual nidus or early venous filling. The dura was closed, the bone flap replaced, and the scalp closed in layers. Strict blood-pressure control was maintained to prevent normal-perfusion-pressure breakthrough. The patient was transferred to the NSICU in stable condition.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Arteriovenous Malformation (AVM) Resection:

Common Pimp Questions

Use these to pressure-test preparation for Arteriovenous Malformation (AVM) Resection:

  1. What is the proximal-control plan before the lesion is manipulated?
  2. Which branch, perforator, or venous structure is most likely to be injured in this exposure?
  3. What are the intraoperative rupture steps, including temporary clip, suction, BP, and backup clip strategy?
  4. What confirms treatment success: ICG, Doppler, puncture/deflation, DSA, or postoperative CTA?
  5. What postoperative BP, vasospasm, antiplatelet, or anticoagulation issue changes the orders tonight?

Attending Preference Variables

Items that commonly vary by surgeon or institution: