Mark Hornyak, MD

This is a 24 year old female who presented to the ER 2 years prior with first time seizure. She is admitted to hospital, evaluated, and released. She did not follow-up with neurosurgery at that time. One year later, again presents to ER with another seizure; undergoes work-up and is again released. 6 months later she follows up with neurosurgeon. She has mild, intermittent visual disturbance

• All
• Pre-Op
• Intra-op
• Post-op

Images from initial CT (left) and CTA (right); apx. 2 years pre-Op. They show moderately sized intracerebral hemorrhage (ICH) in the right parieto-occipital region. CTA is relatively unremarkable; it may show a developmental venous anomaly.

Images from initial MRI brain; apx. 2 year pre-Op. T2 (left) and SWI (right) confirm ICH in right parieto-occipital region.

Images from initial MRI brain; apx. 2 year pre-Op. Pre-contrast (left) and post-contrast (right) T1 images do not show an underlying lesion.

Repeat CT head; performed apx. 6 months pre-op. Image shows new ICH at same right parieto-occipital location.

Cerebral angiogram. AP (left) and lateral (right) projections of the left internal carotid artery injection. No vascular lesion is visualized.

Cerebral angiogram. AP (left) and lateral (right) projections of the left vertebral artery injection. No vascular lesion is visualized.

Repeat MRI brain done apx. 6 months pre-op again showing ICH.

CT head performed immediately preop. Continues to show ICH. CT is also used for surgical navigation (see Figure 8 & Figure 11).

Image showing patient positioning for surgery. Pt is on her stomach (prone) and head is held in a precision head-holder. Planned incision is marked on scalp; minimal clipping of hair also demonstrated. OR equipment in background.

Image captured from surgical navigation system. Showing pre-operative planning of incision and approach to the lesion.

Intraoperative photo showing the surface of the brain after craniotomy has been performed and dura mater has been opened. The surface of the cerebral cortex appears relatively normal.

Intraoperative photo showing microdissection around the lesion. Surgical instrument is being used to dissect and retract lesion in resection cavity. Note the size scale showing the surgical site measures only about ½ inch.

Intraoperative image captured from surgical navigation system showing the link between the surgical microscope and the navigational work-station. Images show the approach to the lesion and roughly correlate with Figure 10.

Intraoperative video showing final removal of the lesion.

Intraoperative image demonstrating the resection cavity after the lesion has been removed.

Photos taken at the completion of the procedure. Image on left shows the incision which has been closed with absorbable suture (dissolving stitches); the right lesion shows the surgical dressing that is applied over the incision.

CT head taken immediately postop. Shows expected changes due to surgery and demonstrates the bone opening used to approach the lesion (craniotomy).

MRI brain acquired 3 months post-op. T2 (left) and SWI (right) images show complete resection of the lesion.