Suboccipital craniectomy with bilateral cerebellomedullary fissure dissection for resection of a ruptured tonsillar/vermian AVM occupying the roof of the fourth ventricle in a pregnant patient

Posterior fossa arteriovenous malformations (AVMs) in pregnant patients can present unique considerations for surgical treatment, including positioning to minimize pressure on the fetus, minimization of radiation exposure, and ethical considerations regarding emergency surgery. This video outlines surgical treatment of a ruptured tonsillar/vermian AVM performed in a staged fashion after emergent suboccipital craniotomy with posterior fossa decompression in the setting of a life-threatening infratentorial hemorrhage. Later, bilateral cerebellomedullary fissure dissection, exposure and dissection of the tela choroidea and inferior medullary velum, and disconnection of arterial feeders from the posterior inferior cerebellar artery (PICA) allowed resection of this AVM occupying the roof of the fourth ventricle. This study was approved by the UCSF Human Research Protection Program IRB no. 18-26938. The video can be found here: https://youtu.be/rTYUGanopUE