Developmental venous anomalies (DVAs) are composed of mature venous vessels that lack malformed or neoplastic elements. Although the hemorrhage risk is considered negligible, some patients may have neurological symptoms attributable to acute infarction or intracranial hemorrhage secondary to thrombosis, in the absence of a coexisting cavernous malformation. We report the case of a 42-year-old patient who presented with acute left-hand paresis secondary to a subcortical hemorrhage. This bleeding originated from a DVA in the corticospinal tract area and was surgically drained through an awake craniotomy. To accomplish this, we used a trans-precentral sulcus approach. After the complete removal of the coagulum, small venous channels appeared, which were coagulated. No associated cavernoma was found. Although the main DVA trunk was left patent, no signs of ischemia or venous infarction were observed after coagulating the small venous channels found inside the hematoma cavity. Two weeks after the procedure, the patient' s hand function improved, and he was able to resume desktop work. DVA-associated hemorrhage within the cortico-spinal tract could be safely removed with modern awake mapping techniques. This technique allowed the patient to rapidly improve his hand function.
Background: Awake craniotomy has become the gold standard in various cranial procedures. As part of the awake technique, three-point pin fixation of the patient’s head is important. One of the issues we encountered is the problem of matching the scalp infiltration site with the final pin position. To overcome this problem, we developed a flat plunger type fixator that adapts to the Mayfield holder. Methods: Our fixator has a 2.5 cm metallic shaft that articulates in a ball and socket joint to allow its concave surfaces to adapt to the patient’s scalp. After placing the patient in the desired position, the head is fixed with the three plungers, circles are drawn around each plunger, and they are then removed for the circles to be infiltrated with bupivacaine. Standard fixation pins are then placed in the Mayfield holder and aimed at the center of the circles. Results: So far, we have operated on 14 patients with this technique. No patient experienced pain during temporary fixation, and the drawn circles ensured that there were no mismatches between the local anesthetic and pin locations. The technique was particularly useful on hairy scalps, where infiltration sites were hidden. We also used only 22.5 mg bupivacaine at the pin sites, freeing a dose for the field block around the scalp incision. Conclusion: The temporary plunger type fixator provided a simple method to economize on local anesthetic use, check the patient’s head position before final fixation, and ensure that the Mayfield pins matched with the anesthetized area.
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