[A midbrain arteriovenous malformation at quadrigeminal plate completely obliterated by embolization]

An eighteen year-old boy presented sudden loss of consciousness and tetraparesis. Radiological examinations revealed a ruptured midbrain arteriovenous malformation (AVM) at the right quadrigeminal plate. The patient recovered from symptoms by conservative treatment over 6 months with residual right hemisensory disturbance and mild diplopia during bilateral horizontal gaze. One year later, he was admitted to our institute for radical treatment of the AVM. On the angiography, the AVM was fed by two branches of the right long circumferential artery and a left paramedian penetrating artery of the posterior cerebral artery (PCA), and drained into the straight sinus via a dilated quadrigeminal vein. After much discussion on several strategies, endovascular surgery was chosen as a radical treatment. In the initial session, a medial branch of the right long circumferential artery was catheterized with Tracker-18, and embolized with 1.0 ml of ethylene vinyl alcohol copolymer (EVAL) without any deficits after negative provocative tests using Amytal and Xylocaine. Then, a lateral branch of the same artery was embolized with 0.8 ml of EVAL in the same way without any deficits. In the second session, catheterization into the left paramedian artery was difficult because of its small diameter and steep branching angle, and only a 3 mm hooked tip of Tracker-18 could be canulated into the feeding pedicle. Left oculomotor palsy was induced by provocative Xylocaine test. However, angiographic cure of the AVM was expected to be made possible by the occlusion of this pedicle, and the procedure was continued due to the request of the patient and his family.(ABSTRACT TRUNCATED AT 250 WORDS)