The Nd:YAG laser in neurosurgery

Part 2. Clinical studies: an adjunctive measure for hemostasis in resection of arteriovenous malformations

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✓ The Nd:YAG laser has been used safely to aid in the resection of 10 cases of parenchymal arteriovenous malformations (AVM's). The laser was, found helpful for: 1) defining the plane between the AVM and the brain; 2) coagulating any dural component of the AVM; and 3) achieving hemostasis of the bed following resection of the lesion. However, its overall benefit in the resection of AVM's remains to be determined, as it could not arrest active high-flow bleeding from the thin-walled vessels feeding the deep portion of the AVM. This was attributed to the inherent characteristics of these vessels, since the instrument has been effective in non-AVM arteries of similar dimensions containing contractile elements in the vessel walls. Future refinements in focusing instrumentation and operative technique should enhance its capabilities and usefulness. When used within the recommended power range, the Nd:YAG laser is safe and its penetration predictable. The fiberoptic cable light delivery system allows excellent mobility of the handpiece, but the protective eyewear laser-light filters reduce the available light to the surgeon. The instrument appears promising but more work is required.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Anteroposterior and lateral views of left carotid (A and B) and left vertebral (C and D) angiograms demonstrating a large arteriovenous malformation involving the glomus of the choroid plexus fed predominantly by the left lateral posterior choroidal arteries, with a lesser supply from the left medial posterior and anterior choroidal vessels. The venous drainage is through the vein of Galen.

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    Case 1. Postoperative angiograms. Anteroposterior and lateral views of the left carotid (A and B) and left vertebral (C and D) injections demonstrating the complete removal of the arteriovenous malformation.

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    Case 2. Arterial and venous phases of left carotid (A and B) and left vertebral (C and D) angiograms demonstrating a left posterior temporal arteriovenous malformation supplied by the lateral posterior choroidal and anterior, middle, and posterior temporal branches of the left posterior cerebral artery. Venous drainage was medially to multiple collateral vessels along the medial surface of the interhemispheric fissure, which drained to the sagittal sinus and the right basal vein. The vein of Galen and the straight sinus were occluded.

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    Case 2. Postoperative angiograms. Anteroposterior and lateral views of the left carotid (A and B) and left vertebral (C and D) injections demonstrating the complete removal of the arteriovenous malformation.

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    Case 3. Anteroposterior (left) and lateral (right) left carotid angiograms demonstrating a left frontoparietal arteriovenous malformation supplied by branches of the left middle cerebral artery, with venous drainage through the left thalamostriate and internal cerebral veins.

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    Case 3. Postoperative anteroposterior (left) and lateral (right) left carotid angiograms following the first resection demonstrating a residual deep periventricular component of the arteriovenous malformation.

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    Case 3. Postoperative anteroposterior (left) and lateral (right) left carotid angiograms 1 week following the second resection of the arteriovenous malformation (AVM) demonstrating a smaller but still evident component of the AVM (compare with Fig. 6).

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    Case 3. Postoperative anteroposterior (left) and lateral (right) left carotid angiograms following the third resection of the arteriovenous malformation. There is no evidence of arteriovenous shunting, but a single deep penetrating artery remained, which continued to fill up to the lesion.

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    Case 9. Anteroposterior and lateral views of left carotid (A and B) and right vertebral (C and D) angiograms demonstrating a large left parietal arteriovenous malformation with multiple feeding vessels from the left anterior, middle, and posterior cerebral arteries.

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    Case 9. Postoperative anteroposterior (left) and lateral (right) left carotid angiograms demonstrating a complete removal of the AVM.

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    Case 10. Lateral right internal (A) and external (B) carotid angiograms and anteroposterior (C) and lateral (D) views of the right vertebral angiogram demonstrating a mixed dural and pial arteriovenous malformation (AVM) of the right temporal lobe. The AVM is supplied by branches of the right middle and posterior cerebral arteries and branches of the right ascending pharyngeal artery.

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    Case 10. Postoperative angiograms. Lateral right internal (A) and external (B) carotid angiograms and anteroposterior (C) and lateral (D) views of the right vertebral angiogram demonstrating the complete removal of the arteriovenous malformation.

References

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