AVMs ofthequadrigeminal plate

GeorgesRodeschMDPhD

Dept ofDiagnosticandTherapeutic Neuroradiology

HôpitalFoch,Suresnes,France

SergeBracard MD

Dept ofClinical Neuroradiology

HôpitalJeanLepoire,Nancy,France NoConflict ofInterest

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Mesencephalon (midbrain)is structurally arelatively simplepartofthebrain inwhich thefundamental relationshipsbetween thebasalandalar platesarepreserved

B.CarlsonHuman Embryology,5thed,Elsevier

Basalplatesform aneuron-rich area:thetegmentum(locationofthesomatic efferent nuclei ofcranial nervesIIIandIV)

Alar plates form sensory part of midbrain (tectum) which subservesfunctions of vision and hearing

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Tectal (quadrigeminal)plateis theportionofthemidbrain tectumupon which thesuperior andinferior collicula sit

In response to the localized expression of En-1 and Pax-7, neuroblasts migrating toward the roof form two prominent pairof bulges: the corpora quadrigemina

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Naidich &Duvernoy

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Caudal part (inferior colliculi) is simple in structureand functionally part of the auditory system

Cranial part (superior colliculi) is more complex inarchitecture and are an integral part of the visualsystem and are a synaptic relay between theoptic nerve and the visual occipital cortex

Connexions between superior and inferior colliculihelp coordinate visual and auditory reflexes20

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Salamon1970

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Collicular artery originates from P1Turns around thepontomesencephalic sulcus ->gives offbranchestothecruscerebriArrivesattectal plateanddivides into a

superior branch forthesuperior colliculusinferior branch orintercollicular artery fortheinferior colliculus andthat participatesextensively tothetectal network« hiding thesubjacentveins »(Duvernoy1975)

Accessory collicular artery forthelateral partofthesuperior colliculusanastomoseswith thevessels ofthecollicular brachium (Pmchor art)

Yasargil

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Supcereb aMedial br

Supcereb aLateral br

Collicular aPostmed chor a

PCA

Pineal glpulvinarOptic tr LGB

MGBSupcolliculus

Inf colliculus+brachium

Supcereb ped

SupMedullvelum

Naidich &Duvernoy

BalancebetweenPmed Chor aand

Collicular a

BalancebetweenCollicular aandSupcereb a

*Arterial networkofinfcolliculus mainly fromsupCereb a(+/- from collic a)*Vascular density atintercollicular sulcus

*vascular networkofsupcolliculus mainly from collicular a*superior edge ofsupcolliculus oftenco-vascularized byPmed Chor a

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Naidich andDuvernoy

Mesencephalon:posterior view

1:Pineal gland

3:supcolliculus

4:inf colliculus

9:collicular art

8:postmed chor art

8:postmed chor art

Suprapinealrecess

10:medial collic v

11:Intercollicular v

pulvinar

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Naidich&Duvernoy

2:pinealgldisplaced upwards

10:supmedianCollic v

3:supcolliculus

4:infcolliculus

8:Collic art

5:precentral v

6:vofbrachium conj

7:supcerebart

9:postmedialchor art

pulvinar

Mesencephalon:posterior view

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Duvernoy

PosteromedialChoroidal a

Collicular art

Supcerebellar a

Numerous anastomosesoneach side butfewanastomosesbetween left andrightnetworks(avascular zonealong verticalintercollicular sulcus)

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Courtesy S.Bracard

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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] .

Green:collicular arteries red:medial superior cerebellar arteries blue posteromedial choroidal arteries

Summary andvariations

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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Naidich &Duvernoy

Coronalsection

pons

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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Yasargil

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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Naidich &Duvernoy

Superficial veins ofcolliculi:less numerous than arteries

Mainly occur atperiphery ofcolliculi andform

-superior median collicular vein-inferior medial collicular vein

Peripheral collicular veins:Emergefrom thesurfaceofcolliculi

Centralcollicular veins:Emergenear themidline

Principallateral veins andthecentralcollicular veins drain

-partofred nucleus-almost alltrochlear andoculomotor

nuclei

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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Naidich &Duvernoy

Pineal gland

ColliculiVenous network

3:supcolliculus

4:infcolliculus

6:intercollicular v6:intercollicular v

5:Supmed collicular v20

18 ©

ABC -

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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pulvinar

Optic tr LGB

MGB

Pineal gl

Supcollic

Inf collic+brachium

Supcerebped

SupMedullvelum

Naidich &Duvernoy

2018

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2018

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2018

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2018

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2018

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2018

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2018

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2018

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Naidich &Duvernoy

pulvinar

Medial geniculate b

Basalv

15:thalamic br ofPostmed chor a

10:postmed chor a

12:supcerebell a‘lat br‘’medial br‘’’supernumerary br

Vth nerveSupcerebell ped

Cruscerebri

11:collicular art

13:latero mesenc v

2018

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2018

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2018

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2018

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2018

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2018

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Naidich&Duvernoy

17:vofsupcerebell ped

Cruscerebri

14:latero mesenceph v

2018

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2018

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2018

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2018

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2018

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Naidich andDuvernoy

1:longitudinalsegmentofprecentral cerebell v

Inf colliculus

Supcolliculus

11:intercollic v

2:dorsalsegmentofprecentral cerebell v

VG

ICV

BV

8:superior cerebell peduncular v

9:precentral lobulev

12:supmedial collicular v

10:vofthecerebellar culmen

2018

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2018

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2018

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2018

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Yasargil

Transmesencephalic supply seen in21%ofmesencephalicAVMs Lasjaunias 1994

2018

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Axial:Superiorcolliculus Axial:Inferior Colliculus

Duvernoy

2018

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2018

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Yasargil

Anterior thalamic perforators ariseproximallyfrom thecaudaldivisionofICAandrunvertically orslightly horizontally

Posterior thalamo perforators arisefrom P1andhaveanearlyverticalsupendymal courseparalleltothebasilararterymaindirectionLateralA° projection:aboveP2towardschoroidregionAPA° projection:closetomidlinebetweenPCAs

Mesencephalicperforatingarterieshaveanhorizontalcourse,perpendiculartothebasilarartery maindirectionAPA° projection:closetomidlineLateral A° projection:below/atlevel ofP2(diff diag with circumflex athat havemorepostcourse)

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Epipial Subpial

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Naidich andDuvernoy

Sectionthrough theinf colliculus Sectionthrough thesuperior colliculus Mesencephalon:sagittalsection

Infcoll

Spinothaltract

SupcollStratumopticum

MRI9,4T

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Vascular Anatomy allows recognitionanddifferential diagnosis ofdifferent vascular malformations

Tectal AVSsCollicular aSupcerebellar aTransmesencephalic aTectal veinPrecentral cerebellar vVGBasalvofRosenthal

Choroidal AVSs Choroidal VGAMs DuralAVFs

Anterior choroidal aPosterior choroidal aSubependymal aChoroidal vVGBasalvRefluxinto contributorsofVGAM

Longcircumferential aAnterior choroidal aPosterior choroidal aChor br ofACALimbic circleSubependymal aMedial vein ofprosencephalonEpsilonaspectofdeep drainageFalcorial sinus

Duralfeeders(MMA,APhA,occip a,Supcerebellar,PCA,ICA…)VGVeins oftheregion

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Rareandsmall (surgical)series ofbrainstem AVMs

Drake1986 15pts 7« midbrain » series aboutPFAVMs:61/66Hb(butnoprecision oflocalization)

Solomon&Stein1986 12pts 4« tectal plateregion » allHb

Yasargil 1988 14pts 9« dorsal/dorsolateral mesencephalon »revealing Hb in6operated ptsnoinfoaboutrevealing sympt innonoperated pts

Brainstem AVMs:Rarelesions (2-6%ofallbrain AVMs)Tectal plateAVMs?

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Yasargil brainstem AVMsThere are 6 operated and 8 unoperated cases in thepresent series.Three of the operated cases were in the dorsalmesencephalon. Two of these were small and locatedaround the left superior colliculus. The third waslocated within the pineal body. In these cases ahematoma had developed a plane of cleavage andextended down towards the habenular commissure.These 3 cases were operated upon successfully and theonly residual deficit was a temporary Parinaud's syndromein one case (No. 1, 2, 3, Table 4.132, Figs 4.174 and4.175 in Vol. IIIB, see also Figs 3.31, 3.32 and 3.100,Vol. IIIA). It is interesting to note that these AVMswere barely seen on preoperative angiography and wereidentified by the early appearance of a dorsalmesencephalic vein.

Threeothercaseswereinthedorsolateralmesencephalon

Onecase(No.6,Table4.132)wasunusual,asmultipleAVMswerepresentaroundthemesencephalon,

In2furthercasestheAVMwasintherightparacollicular area involvingthenervesIVandV,butfortunatelyepipial andpartiallysubpial.Thefeederswerecoagulateduntilthedrainingvesselsturnedtodarkbluethenthelesionwasremoved.Thepostoperativecoursewasuneventfulinbothcases

Outof189patientswithdeepcentralAVMs,153havebeenoperatedand36notoperated.In6patientswithparasplenial,4withcallosal,1withtrigonal-plexal and3withdorsalmesencephalicAVM,thelesionscouldhavebeensurgicallyremovedbutthepatientsortheirrelativesrefusedsurgery.

Ofnonoperated patients,atotalof19underwentirradiation

Table7.6Statisticaldatain20nonoperated patientswhodied

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Yasargil

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Rareandsmall (surgical)series ofbrainstem AVMs

Drake1986 15pts 7« midbrain » series aboutPFAVMs:61/66Hb(butnoprecision oflocalization)

Solomon&Stein1986 12pts 4« tectal plateregion » allHb

Yasargil 1988 14pts 9« dorsal/dorsolateral mesencephalon »revealing Hb in6operated ptsnoinfoaboutrevealing sympt innonoperated pts

Lawton&Spetzler 1995 10pts NASpetzler &Martin1986

Nozaki 2006 25pts 9 « dorsalmidbrain » 9initialHb.3repeated Hb

Kelly&Steinberg2008 29pts NA

Han&Lawton2015 29pts 6« posterior midbrain » Hb in23pts(79,3%)

Madhugiri &Steinberg2017 39pts 11« posterior midbrain » Hb in36pts(92,3%)

Brainstem AVMs:Rarelesions (2-6%ofallbrain AVMs)Tectal plateAVMs?

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Haemorrhage SAH/IVH

Intraparenchymatous

Noprecise informationabouttheannual hemorrhagic rateoftectal AVMs

Annual Hb risk Brainstem AVMs 15,1%- 17,5%Koga 2011,Nozaki 2006,Han2015,Madhugiri 2017

Annual Rebleeding risk Brainstem AVMs 14,2%Nozaki 2006

Severe Neurological Symptomssomnolence–>comaIIIIVpalsyataxiahemiparesishemihypoesthesiaverticalgazepalsycerebellar syndromeauditory troubles…

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Posterior fossa AVMs

75-95%cerebellar5-25%brainstem Drake1986;George1992;Spetzler 2015

Spetzler 2015

Thesupracerebellar infratentorial approachisusuallyusedforAVMsofthetectal plateandthesuperiorsurfaceofthecerebellum,providedtheydonotextendabovetheincisura(needforaposteriorinterhemisphericapproach)

SolomonRAandSteinB;Neurosurgery1986HanSJandLawtonM;JNeurosurg 2015

Occipitalinterhemispheric transtentorial approachMcLaughlin NandMartinNA;WorldNeurosurg 2014

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Clinical &morphological outcomes after therapeutic management(brainstem!Tectum?)

Surgery Better outcome ifepipial than subpial

Totalexcisionvs retrograde venonidal microsurgical obliterationSteigerHJ,Hänggi D2009

« occlusioninsitutechnique »Han&Lawton2015,Madhugiri &Steinberg2017(already Yasargil 1988…)

*Postsurgical outcome influenced bypresurgical condition*Rateofworsening/death greatest with posterior midbrainandanterior pontineAVMs Han&Lawton2015

*Postsurgical permanentcomplicationrateis 13,8-25%Han&Lawton2015Nozaki 2006

Han&LawtonExample ofOPlateral medullary AVM

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Rareandsmall (endovascular)series ofbrainstem AVMs

Amidbrainarteriovenousmalformationatquadrigeminal platecompletelyobliteratedbyembolizationNakahara&al;NoShinkei Geka 1993

18ymale.Hb =>tetraparesis.Recovery 6months with residual Rhemisensory disturbance andParinaud2sessionsofE° with EVALafter provocative tests(Amytal andXylocain).Left oculomotor nervepalsy.CureofAVM

Endovascular treatment ofbrainstem arteriovenous malformations:safety andefficacyHMLiu&al,Neuroradiology 2003

1dorsalmidbrain Hb1centralanddorsalmidbrain Hb1pulvinar anddorsalmidbrain Hydrocephalus

Alltransmesencephalic feedersAllintranidal AA

E° glue partialtreatment (2x75%occlusion,1x90%occlusion)FUoutcome:2xgood,1xfair

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Rareandsmall (endovascular)series ofbrainstem AVMs

Achallenging entity ofendovascular embolization with Onyxforbrainstem arteriovenous malformations.Experience from 13cases

JinH&al;Interv Neuroradiol 2017

9posterior midbrain AVMs.8Hb.1Headaches1intranidal AAonfeeder

2cured byE°.7partialE° +additional GammaKnife

Nocomplicationinthe2cured ptsandin3partially treated pts1death (brainstem infarction)1Hb with poor outcome (mRs 3)2transient diplopia (mRs 0and1atmean FU45,3months)

Aproposed grading systemtoevaluate theendovascular curability ofdeep-seated arteriovenous malformationsTh.Robert&al;JNeurol Sci 2017

5groups.Group5:midbrain (nospecificity ofanatomical area:centered inmidbrain:N=15)10E°.3Cured

Radiationtherapy inothers

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Morepublicationsaboutradiosurgery andbrainstem AVMs …butrarespecificity abouttectal AVMs…

MicrosurgeryandradiosurgeryinbrainarteriovenousmalformationsSteinerL&al;JNeurosurg 1993

57brainstemAVMs(tectum?)Completeobliterationin71,4%ofptsafter2yearsFUButnoinformationaboutclinicalcharacteristics,treatmentparametersandadverseevents

PredictionofresultsfollowingGammaKnifesurgeryforbrainstemandothercentrallylocatedarteriovenousmalformations:relationtonaturalcourse.

Karlsson B&al;Stereotact Funct Neurosurg 1996

CentrallylocatedlesionscarryhigherrisksofcomplicationsthanthoselocatedperipherallyPositiverelationshipbetweentheminimumdosegiventotheAVMnidusandtheincidenceofobliterationTheaveragedosetovolumesthatarelargeforradiosurgeryisrelatedtotheincidenceofcomplications

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ResultsofradiosurgeryforbrainstemarteriovenousmalformationsKuritaH&al;JNNP2000

“Radiosurgeryisconsideredasavalidtreatment(…)itisalsoknowntocauseseriousneurologicaldeteriorationwhenusedforbrainstemlesions”“(…)thetreatmentofchoiceforbrainstemAVMslocatedwithintheparenchyma”“posttreatmenthemorrhageremainsasignificantproblemwiththistechnique…”

10tectal AVMs

NodescriptionoftheoutcomeofthisspecifictypeofbrainstemAVMs,but:“twopatientswithmidbrainAVMsexperiencedsymptomaticradiationinjury7and24monthsafterirradiation:ptosisandataxiainone,eyemovementdisorderintheotherone”Þ steroids.Resolutionofsymptomswithin1year.Nopermanentdeficitrelatedtoradiosurgery

GammaKnife radiosurgeryforbrainstemarteriovenousmalformations:preliminaryresultsMassagerN&al,JNeurosurg 2000

2tectopineal AVMsOverallresultswithnofocusonthespecificlesions

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Kurita &alJNNP2000

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Stereotacticradiosurgeryforbrainstemarteriovenousmalformations:factorsaffectingoutcomeMaruyamaK&al,2004

Anolderpatientage,alesionlocatedinthetectum,andahigherradiosurgery-basedscoreweresignificantlyassociatedwithgreaterneurologicalcomplications

Stereotactic Linac based radiosurgery inthetreatment ofarteriovenous malformationslocated deep involvingcorpuscallosum,motor cortexorbrainstem

Zabel-DuboisA&alInt.J.RadiationOncology Biol Phys 2006

5brainstem AVMs (localization?)« SizeofAVMandapplied singledosewere determined assignificant factors affecting successful obliteration »

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Stereotactic Linac based radiosurgery inthetreatment ofarteriovenous malformationslocated deep involvingcorpuscallosum,motor cortexorbrainstem

Zabel-DuboisA&alInt.J.RadiationOncology Biol Phys 2006

5brainstem AVMs (localization?)« SizeofAVMandapplied singledosewere determined assignificant factors affecting successful obliteration »

GammaKnife Radiosurgery forarteriovenous malformationsofbasalganglia,thalamusandbrainstem- aretrospectiveStudy comparing theresults with that forAVMs atother intracranial locations

KiranNA&al;ActaNeurochir 2009

« CentralAVMs »…..Nodistinctionoftypeoflesions andlocalizationOnly sizeanddose…

Javalkar V&al,Neurol India 2009Effectivemodality oftreatment forcentralAVMs

YenCPandSteinerLWorldNeurosurg 201142midbrain AVMs«When therisks ofsurgeryorembolizationarehighortherearestillpatentAVMs,GKSshouldbeconsideredasatreatmentalternativeifthenidusislocatedinthesubpial orepipial area,and itshouldalwaysbeusedwhenthenidusisdeepintheparenchymaofthebrainstem.Inthepresentseries,GKSachievedacompleteobliterationrateof59%.Tothisresultshouldbeaddedthehigherriskofradiation-induced complications. »

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Stereotactic radiosurgery forarteriovenous malformationslocated indeep critical regionsNagyG&al,Neurosurgery 2012

Aftersingletreatment,obliterationwasachievedin65%ofthebrainstem,in69%ofthesupratentorial,and40%oftheperitectal AVMs.Obliterationoflesions<4cmwasbetterinthebrainstem(70%)andinthesupratentorium (80%),butnotintheperitectal region(40%).

Managementoutcome ofbrainstem arteriovenous malformations:therole ofradiosurgeryYangW&al,WorldNeurosurgery 2016

“Thedistributionofbrainstemlocationsinourcohortwas63.3%midbrain…”

Etc ….Etc…Brainstem….Sometimes mesencephalon…rarely tectal /quadrigeminal plate…

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InFoch,Nancyandnetwork

26ptswith quadrigeminal areaAVMs 20Nancy9epipial 11subpial6Foch4epipial 2subpial

Revealing symptoms 22Hb (84,6%)1fortuituous discovery (associated temporalAVM)3neuro(gazepalsy/paresis ->diplopia…)

Feeders Mostly Collicular a,Superiorcerebellar a

Venous drainage Precentral cerebellar vein /Latero mesencephalic vein (epipial)(Morecomplex venous drainagesforsubpial lesions)

AssociatedAAorfalseAA 1/26(subpial).0inepipial

Sizeoflesion From punctiform (epipial)tosmall nidus

2018

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Therapeutic strategies andoutcomes 17ptstreated Nancy6ptstreated FochTrtt in23pts/26E° 20glue/1Onyx

E° alone Rxtherapy alone E°+Rxth Total

Cure(Totalocclusion)6*15**12

Incomplete occl 6*** 129

Waiting forresults 22

Total 122923

*1recurrence 10ylater (=>diplopia.2nd E° +Rxth)

**1recurrence 7ylater (=>Holmestremor.2nd RXth)

***2early rebleeds atD4andD10(1death;1waiting forcomplementary trtt)1ptOnyx.OcclusionSupcereb a.Development angiogenesis +duraladh (waiting forRxth)3lost FU

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ReHb 5y.Further Trttindiscussion

Further trtt indiscussion

2018

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PartialrecoveryDiplopia,hypoesthesiaRupper limb

Radiosurgery 2012->Noeffect

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

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n eve

n in p

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proh

ibited

] .

Decision forradiosurgery(performed 2013)

2018

© A

BC - W

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ohibi

ted.

2018

© A

BC - W

IN S

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r. All r

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Any

repr

oduc

tion e

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n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n in p

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proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n in p

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proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

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] .

2018

© A

BC-WIN

Sem

inar. A

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proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n in p

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proh

ibited

] .

2018

© A

BC - W

IN S

emina

r. All r

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rese

rved -

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repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC - W

IN S

emina

r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

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serve

d - A

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proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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serve

d - A

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prod

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n in p

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proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

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d - A

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prod

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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serve

d - A

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prod

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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serve

d - A

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] .

2018

© A

BC-WIN

Sem

inar. A

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ts re

serve

d - A

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prod

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC - W

IN S

emina

r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC - W

IN S

emina

r. All r

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rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

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ted.

2018

© A

BC-WIN

Sem

inar. A

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serve

d - A

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prod

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

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proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

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proh

ibited

] .

Fborn1967

Infcollic

2018

© A

BC - W

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ohibi

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2018

© A

BC - W

IN S

emina

r. All r

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rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

Stagnation…

ADCmapVasogenic edema

2018

© A

BC - W

IN S

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r. All r

ights

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ohibi

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2018

© A

BC - W

IN S

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r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

After steroid therapy

Rebleed 10ylater onthesame sitefrom arecurrent AVM….

6mA° control

2018

© A

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2018

© A

BC - W

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r. All r

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Any

repr

oduc

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t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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n in p

art is

proh

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] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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serve

d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

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n in p

art is

proh

ibited

] .

F21yheadaches,intermittentstrabismus,sensationsofloss ofequilibrium

2018

© A

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2018

© A

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r. All r

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Any

repr

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n par

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ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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prod

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n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

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d - A

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n eve

n in p

art is

proh

ibited

] .

2018

© A

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n in p

art is

proh

ibited

] .

Symptoms : venous congestion of quadrigeminal plaque and mesencephalic

structures involved in oculomotricity

Venous congestion of the posterior fossa

tonsilar prolapse

GirardNetalReversibletonsilar prolapseinVGAMs:reportof8casesandpathophysiologicalhypothesis.ChildsNerv Syst 10:141-147,1994

hydromyelia

2018

© A

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ohibi

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2018

© A

BC - W

IN S

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r. All r

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Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

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n eve

n in p

art is

proh

ibited

] .

Mborn in1956Operated forstrabism in1972

Followed for>20y.NohemorrhageTherapeutic Abstention(subpial!)Diplopia

2018

© A

BC - W

IN S

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ights

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ohibi

ted.

2018

© A

BC - W

IN S

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r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

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d - A

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prod

uctio

n eve

n in p

art is

proh

ibited

] .

Conclusions

Tectal/posterior midbrain/quadrigeminal AVMs small size

Epipial vsSubpial

Hemorrhagic presentation

Simplearchitecturerareassociated AAsingle(main)draining vein

Challenging lesions:Surgical treatment Cureifepipial…butrisks morbi-mortality (specially ifintraparenchyma)Embolization Fewcures

DangerofOnyx(contraindication?:reflux;penetration;toxicity DMSO)Glueokbutneeds occlusionfootofvein(challenging andrisky because ofvascular network)AngiogenesisTransvenous approach??

2018

© A

BC - W

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r. All r

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Any

repr

oduc

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ven i

n par

t is pr

ohibi

ted.

2018

© A

BC - W

IN S

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r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

collicular vandprecentral vM15yDiplopia

Residual IVth npalsyPostE° (glue)andpostradiosurg (noresult)

Failure transvenous approach.Surgery?

2018

© A

BC - W

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ights

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tion e

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ohibi

ted.

2018

© A

BC - W

IN S

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r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

prod

uctio

n eve

n in p

art is

proh

ibited

] .

Conclusions

Tectal/posterior midbrain/quadrigeminal AVMs small size

Epipial vsSubpial

Hemorrhagic presentation

Simplearchitecturerare/exceptional associated AA(specific biology oftectal plate?)one(two…)draining veins

Challenging lesions:Surgical treatment Cureifepipial…butrisks morbi-mortality (specially ifintraparenchyma)Embolization Fewcures

DangerofOnyx(contraindication?:reflux;penetration;toxicity DMSO)Glueokbutneeds occlusionfootofvein(challenging andrisky because ofvascular network)AngiogenesisTransvenous approach??

Radiosurgery Risk ofrebleeding inthelatency period.Higher risks fortectal AVMs

Combination andassociationoftreatments.Selection ofpatients.Need forlongFUs

2018

© A

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ohibi

ted.

2018

© A

BC - W

IN S

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r. All r

ights

rese

rved -

Any

repr

oduc

tion e

ven i

n par

t is pr

ohibi

ted.

2018

© A

BC-WIN

Sem

inar. A

ll righ

ts re

serve

d - A

ny re

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uctio

n eve

n in p

art is

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