The Technique of Limited Quadrangular Lobe Removal to Safely Resect a Quadrigeminal Plate Arteriovenous Malformation: 2-Dimensional Operative Video

Abstract

Arteriovenous malformations in the brainstem are among the most challenging to manage. They represent between 7% and 15% of all brain arteriovenous malformations (AVMs). The high risk of hemorrhage eloquence and increased susceptibility to adverse radiation effects restricts the management of such cases to experienced centers. 1,2 The latency associated with radiosurgery, poor results from embolization as primary therapy all make surgery a favored option in experience hands. 3 A good understanding of the anatomy, arterial supply, and venous drainage of this region is required to safely manage pathology located here. 4,5 There are 2 main patterns of AVMs seen in the midbrain. A type restricted to the pial with exophytic appearance and a second truly parenchymal location. 6 The goal of surgery is to eliminate the risk of hemorrhage and avoid ocular motility and morbidity. An occipital transtentorial approach is often considered when a steep tentorial angle is encountered. [6][7][8] We present a video case of the surgical resection of an exophytic quadrigeminal plate AVM. The patient, a 42-year-old man, presented with a sudden and intense headache, without neurological deficit. MRI and digital subtraction angiography revealed a 2 cm AVM located in the right inferior colliculi supplied by branches of the posterior cerebral artery with early venous drainage into the vein of Galen. The patient consented to the procedure. We demonstrate the supracerebellar infratentorial corridor with a limited resection of the quadrangular lobule to remove the AVM. The case highlights the key anatomic landmarks required to safely modify this classic approach.

Commentary: The Technique of Limited Quadrangular Lobe Removal to Safely Resect a Quadrigeminal Plate Arteriovenous Malformation: 2-Dimensional Operative Video

“…In this video article, 10 the authors present an interesting case of exophytic quadrigeminal plate AVM, which presented clinically with a sudden onset of intense headache, without any neurological deficits. Magnetic resonance imaging and digital subtraction angiography revealed a 2-cm AVM located in the right inferior colliculus, supplied by the posterior cerebral artery, with venous drainage into the vein of Galen.…”

“…As illustrated in the video, 10 the patient was operated in the semisitting position through an infratentorial approach expanded by partial resection of the quadrangular lobe (with exposure of the cerebellomesencephalic fissure), to improve visualization of the lesion area. After resecting part of the quadrangular lobe, proper microsurgical circumferential dissection of the AVM was performed starting from its inferolateral aspect, arterial feeders were coagulated and disconnected, the nidus was dissected from the inferior colliculus and resected, and the main draining vein was finally coagulated and divided.…”

“…Total resection of the malformation is recommended if it is purely pial, whereas parenchymal malformations are treated by partial resection of the nidus and/or coagulation of arterial feeders and draining veins. 9 In this video article, 10 the authors present an interesting case of exophytic quadrigeminal plate AVM, which presented clinically with a sudden onset of intense headache, without any neurological deficits. Magnetic resonance imaging and digital subtraction angiography revealed a 2-cm AVM located in the right inferior colliculus, supplied by the posterior cerebral artery, with venous drainage into the vein of Galen.…”