The Nightmare of AVM Surgery: Early Rupture of the Venous Drainage-Lessons from Personal Experience and a Review of the Literature.

We describe the case of a 72-year-old man who presented with signs of increased intracranial pressure, right-sided motor deficit, and repeated episodes of epilepsy due to a left frontal arteriovenous malformation (AVM) with a large superficial draining vein. Despite great efforts to protect the vein from the start, it ruptured shortly after we removed the bone flap. This required rigorous hemorrhage control, which in turn led to profuse bleeding from the nidus throughout the process of the dissection and coagulation of the arterial feeders. The postoperative course was initially uneventful; however, the patient declined neurologically and became unresponsive on the second day after surgery. Emergent CT revealed a significant hematoma occupying the space where the AVM nidus had been resected. The patient was taken back to the OR for emergency evacuation of the hematoma. Despite these efforts, the neurological status remained poor, and the patient was transferred to a territorial hospital after spending 3 weeks in the ICU.An early rupture of the venous drainage represents a dreaded complication of AVM surgery, which can compromise the intervention before the start of the definite resection. We discuss our experience of and strategy for preventing and managing the intraoperative venous rupture of AVMs by describing our seven rules of "Don't." We also provide a brief overview of the relevant literature.