We report a difficult case of endoscopic hematoma evacuation due to micro-arteriovenous malformation (AVM).
A 60-year-old male presented with left hemiparesis and confusion. Computed tomography demonstrated right putaminal hemorrhage, but cerebral angiography revealed no definite vascular abnormalities. Endoscopic hematoma evacuation was immediately undertaken using a transparent sheath. Massive arterial hemorrhaging occurred following hematoma decompression, so endoscopic evacuation was aborted and open craniotomy initiated. Arterial bleeding from around the hematoma cavity indicated occult arteriovenous fistula. After evacuation of the hematoma, abnormal vessels were identified and completely resected. Pathological diagnosis was an arteriovenous malformation and clinical diagnosis was micro-AVM, as described by Yasargil in 1987.
The point of endoscopic hematoma evacuation using a transparent sheath was to position the burr hole for keyhole surgery rather than stereotaxic aspiration. If micro-AVM is suspected during the endoscopic procedure, the procedure must be changed to open craniotomy. The best burr hole position also provides the optimal approach for open craniotomy. Operative instruments and procedures must be developed to improve safety for this endoscopic surgery.
