Meticulous haemostasis is one of the most important factors during microneurosurgical resection of brain arteriovenous malformation (AVM). Controlling major arterial feeders and draining veins with clips and bipolar coagulation are well-established techniques, while managing with bleeding from deep tiny vessels still proves to be challenging. This technical note describes a technique used by the senior author in AVM surgery for last 20 years in dealing with the issue highlighted.
“Dirty coagulation” is a technique of bipolar coagulation of small feeders carried out together with a thin layer of brain tissue that surrounds these fragile vessels. The senior author uses this technique for achieving permanent haemostasis predominantly in large and/or deep-seated AVMs. To illustrate the efficacy of this technique, we retrospectively reviewed the outcome of Spetzler-Martin (SM) grade III-V AVMs resected by the senior author over the last 5 years (2010–2015).
Thirty-five cases of AVM surgeries (14 SM grade III, 15 SM grade IV and 6 SM grade V) in this 5-year period were analysed. No postoperative intracranial haemorrhage was encountered as a result of bleeding from the deep feeders. Postoperative angiograms showed complete resection of all AVMs, except in two cases (SM grade V and grade III).
“Dirty coagulation” provides an effective way to secure haemostasis from deep tiny feeders. This cost-effective method could be successfully used for achieving permanent haemostasis and thereby decreasing postoperative haemorrhage in AVM surgery.
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We would like to thank Yaroslava A. Kozyreva for the drawings in this article.
No funding was received for this research.
Conflict of interest
Professor Juha Hernesniemi is an Aesculap counsellor. All other authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
For this type of study formal consent is not required.
Informed consent was obtained from all individual participants included in the study.
This article does not contain any studies with human participants performed by any of the authors.
This is a technique that Dr. Hernesniemi is known to have pioneered and promoted. When introduced it defied the conventional wisdom, at the time, of fine bipolar technique applied to the vessel with no collateral damage to be inflicted on surrounding tissue. However, for AVM this technique often fails for reasons presented in this paper and this “dirty coagulation” technique is necessary. It is important for those charged with the care of AVM to be aware of this technique and who first promoted its use. I have seen Dr. Hernesniemi use this and have adopted this technique, where appropriate, for my own AVM cases.
Michael Kerin Morgan
I think this is a helpful contribution because it shows the way to a very useful, albeit counterintuitive technique for coagulating tiny vessels. I have used this technique for decades and never bothered to write about it because it is so obviously the only technique that works in the deep white matter around AVMs. I am sure that this technique has been used by many other AVM surgeons also because it is a logical development. As it has been demonstrated, the intuitive decision to use fine-tipped forceps for fine vessels is wrong for fine vessels in the white matter around AVM, just as many other spontaneous intuitive decisions made by medical doctors.
Microclips are a good alternative method, but I can confirm many of the observations the authors have made: too many microclips soon turn out to be in the way when dealing with other small feeders. These difficult feeders in deep become more common the closer one is to the ependyma of the ventricle. The microclips produce short-cuts when bipolar is used close to them and they can shear off. This reviewer also confirms that the use of broader bipolar tips is very useful, because the current flow is not so focused as in finely tipped bipolar forceps. Thus, sticking to the coagulated vessel is less frequent when using broader tipped forceps. This somehow automatically leads to the technique that these authors have named “dirty coagulation”. A major part of the trick of “dirty coagulation” is to include some tissue around the vessel between the two forceps tips (as described) but also to use a not too high current and take some time with a low flow of electric current in order to allow the tissue to shrink slowly and desiccate slowly. The speed of shrinking and desiccation is an important feature, because if this happens too quickly these fragile feeders may tear 2–3 mm away from the coagulation forceps because they are torn away.
The apparently logical step of using very fine forceps and only enclosing the tiny vessel just does not work in the deep white matter around AVM. This reviewer has used blunt forceps 95% of the time during his own large AVM series . The counterintuitive step of using broad-tipped forceps turns out to be more effective and better suited.
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Kozyrev, D.A., Thiarawat, P., Jahromi, B.R. et al. “Dirty coagulation” technique as an alternative to microclips for control of bleeding from deep feeders during brain arteriovenous malformation surgery. Acta Neurochir 159, 855–859 (2017). https://doi.org/10.1007/s00701-017-3138-8
- Arteriovenous malformation
- Bipolar coagulation
- Neurosurgical trick