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

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- 8) We present a video case of the surgical resection of an exophytic quadrigeminal plate AVM. The patient, a 42-year-oldman, 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.

Automated summary

Arteriovenous malformations in the brainstem are challenging to manage, accounting for 7% to 15% of all brain arteriovenous malformations. The high risk of hemorrhage and vulnerability to radiation effects limit their management to experienced centers. Surgery is often preferred due to the delayed effects of radiosurgery and poor results from embolization. A good understanding of the anatomy and blood supply is necessary for safe management.