AVMs ofthequadrigeminal plate
GeorgesRodeschMDPhD
Dept ofDiagnosticandTherapeutic Neuroradiology
HôpitalFoch,Suresnes,France
SergeBracard MD
Dept ofClinical Neuroradiology
HôpitalJeanLepoire,Nancy,France NoConflict ofInterest
2018
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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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ibited
] .
Courtesy S.Bracard
2018
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BC - W
IN S
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rese
rved -
Any
repr
oduc
tion e
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t is pr
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ted.
2018
© A
BC - W
IN S
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r. All r
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rved -
Any
repr
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ted.
2018
© A
BC-WIN
Sem
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d - A
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] .
2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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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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] .
Green:collicular arteries red:medial superior cerebellar arteries blue posteromedial choroidal arteries
Summary andvariations
2018
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BC - W
IN S
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r. All r
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rved -
Any
repr
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tion e
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2018
© A
BC - W
IN S
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r. All r
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Any
repr
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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d - A
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] .
2018
© A
BC-WIN
Sem
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d - A
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2018
© A
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Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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ll righ
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d - A
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] .
Naidich &Duvernoy
Coronalsection
pons
2018
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IN S
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Any
repr
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2018
© A
BC - W
IN S
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r. All r
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Any
repr
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
inar. A
ll righ
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d - A
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n in p
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proh
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] .
Yasargil
2018
© A
BC - W
IN S
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r. All r
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rese
rved -
Any
repr
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tion e
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n par
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2018
© A
BC - W
IN S
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r. All r
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Any
repr
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2018
© A
BC-WIN
Sem
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d - A
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] .
2018
© A
BC-WIN
Sem
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ll righ
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d - A
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] .
2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
inar. A
ll righ
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d - A
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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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r. All r
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Any
repr
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2018
© A
BC - W
IN S
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r. All r
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rese
rved -
Any
repr
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tion e
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2018
© A
BC-WIN
Sem
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serve
d - A
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] .
2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
inar. A
ll righ
ts re
serve
d - A
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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 -
WIN
Sem
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.
2018
© A
BC - W
IN S
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Any
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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serve
d - A
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
BC-WIN
Sem
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2018
© A
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Sem
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2018
© A
BC-WIN
Sem
inar. A
ll righ
ts re
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d - A
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] .
pulvinar
Optic tr LGB
MGB
Pineal gl
Supcollic
Inf collic+brachium
Supcerebped
SupMedullvelum
Naidich &Duvernoy
2018
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BC - W
IN S
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r. All r
ights
rese
rved -
Any
repr
oduc
tion e
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2018
© A
BC - W
IN S
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r. All r
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Any
repr
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2018
© A
BC-WIN
Sem
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d - A
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2018
© A
BC-WIN
Sem
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d - A
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] .
2018
© A
BC-WIN
Sem
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] .
2018
© A
BC-WIN
Sem
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] .
2018
© A
BC-WIN
Sem
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2018
© A
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Sem
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2018
© A
BC-WIN
Sem
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d - A
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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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Any
repr
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2018
© A
BC - W
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Any
repr
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2018
© A
BC-WIN
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d - A
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2018
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Sem
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2018
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Sem
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2018
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Sem
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2018
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2018
© A
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Sem
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2018
© A
BC-WIN
Sem
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Naidich&Duvernoy
17:vofsupcerebell ped
Cruscerebri
14:latero mesenceph v
2018
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ights
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Any
repr
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2018
© A
BC - W
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Any
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2018
© A
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2018
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Sem
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2018
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2018
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2018
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2018
© A
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Sem
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2018
© A
BC-WIN
Sem
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d - A
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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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ights
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Any
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tion e
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2018
© A
BC - W
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Any
repr
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2018
© A
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Sem
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2018
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Sem
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2018
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Sem
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2018
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Sem
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2018
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2018
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2018
© A
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Sem
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Yasargil
Transmesencephalic supply seen in21%ofmesencephalicAVMs Lasjaunias 1994
2018
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ights
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repr
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2018
© A
BC - W
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2018
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2018
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Sem
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2018
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Sem
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2018
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Sem
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2018
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Sem
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2018
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Sem
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2018
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BC-WIN
Sem
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d - A
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Axial:Superiorcolliculus Axial:Inferior Colliculus
Duvernoy
2018
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BC - W
IN S
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ights
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repr
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2018
© A
BC - W
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Any
repr
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2018
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BC-WIN
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2018
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BC-WIN
Sem
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2018
© A
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Sem
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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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2018
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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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2018
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2018
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2018
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ibited
] .
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
2018
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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
2018
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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. »
2018
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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…
2018
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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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2018
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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
1spont occl1abstention1waiting forE°
ReHb 5y.Further Trttindiscussion
Further trtt indiscussion
2018
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31yFHb 2011HeadachesTinnitusGazepalsyRhemihypoesthesiaLhemiparesis
PartialrecoveryDiplopia,hypoesthesiaRupper limb
Radiosurgery 2012->Noeffect
2018
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2018
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2018
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2018
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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
ny re
prod
uctio
n eve
n in p
art is
proh
ibited
] .
Decision forradiosurgery(performed 2013)
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
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
] .
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
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
] .
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
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
] .
Fborn1967
Infcollic
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
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
] .
Stagnation…
ADCmapVasogenic edema
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
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
] .
After steroid therapy
Rebleed 10ylater onthesame sitefrom arecurrent AVM….
6mA° control
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
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
] .
F21yheadaches,intermittentstrabismus,sensationsofloss ofequilibrium
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
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
] .
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
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
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
] .
Mborn in1956Operated forstrabism in1972
Followed for>20y.NohemorrhageTherapeutic Abstention(subpial!)Diplopia
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
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
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
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
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
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
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
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
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
] .