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cerebellar_arteriovenous_malformation_classification

Cerebellar Arteriovenous Malformation Classification

Yasargil categorized 58 cerebellar AVMs into 7 types:

Hemispheric (superior and inferior, divided by the horizontal fissure)

Vermian (superior and inferior, divided by the horizontal fissure)

Cerebellopontine

Giant

Fistula 1).


Rhoton and colleagues described 3 cerebellar surfaces (suboccipital, tentorial, and petrosal) in their anatomical studies, but did not apply this to AVMs specifically 2).


Rodriguez-Hernandez et al. adapted these efforts to define 5 distinct subtypes of cerebellar AVMs: suboccipital, vermian, tonsillar, tentorial, and petrosal. They found these subtypes offer an intuitive appreciation of their anatomy and surgical management, and are useful in describing surgical results. A focused analysis of outcomes after cerebellar AVM resection enables assessment of a patient selection 3).

Suboccipital AVMs are based on the posterior cerebellar surface facing the occipital bone, located below and between the transverse and sigmoid sinuses. The hemispheric portion of the suboccipital surface is comprised of the superior semilunar, inferior semilunar, and biventral lobules. The suboccipital surface is divided into superior and inferior parts by its major fissure, the suboccipital fissure. Minor fissures on the suboccipital surface include the petrosal or horizontal fissure (between superior and inferior semilunar lobules), the prebiventral fissure (between inferior semilunar and biventral lobules), and the tonsillobiventral fissure. AVMs based on the vermian portion of the suboccipital surface are categorized as vermian.

Tentorial AVMs are based on the tentorial surface. The hemispheric part of the tentorial surface is comprised of the quadrangular, simple, and superior semilunar lobules. The tentorial surface is divided into anterior and posterior parts by its major fissure, the tentorial or primary fissure. This fissure separates the quadrangular and simple lobules on the hemisphere, and the culmen and declive on the vermis. The postclival fissure separates the simple and superior semilunar lobules. AVMs based on the vermian portion of the tentorial surface are categorized as vermian.

Petrosal AVMs are based on the petrosal surface, the anterior cerebellum that faces the posterior petrous bone. The cerebellopontine angle is the V-shaped cerebellopontine fissure formed where the hemispheric lobules wrap around the pons and middle cerebellar peduncle. The petrosal surface is divided into superior and inferior parts by the petrosal or horizontal fissure, which extends onto the suboccipital surface between the superior and inferior semilunar lobules. The superior and inferior limbs of the cerebellopontine fissure meet laterally at the apex of the CP angle, at the anterior end of the petrosal fissure. The petrosal surface is formed by the anterior surfaces of the quadrangular, simple, semilunar, and biventral lobules, and the flocculi.

Vermian AVMs lie in the midline and may be on the tentorial surface or on the suboccipital surface. The inferior vermis lies in a deep vertical depression in the suboccipital surface called the posterior cerebellar incisura, which also contains the falx cerebelli. The inferior vermis forms the posterior cortical surface within this incisura. In contrast, the superior vermis is the highest point on the cerebellum, occupying the space under the straight sinus where the tentorial leaflets intersect with the falx cerebri. The superior vermis slopes downward from its apex anteriorly to the posterior cerebellar incisura. The tentorial part of the vermian surface includes (from anterior to posterior) the culmen, declive, and folium. The suboccipital part of the vermian surface includes (from superior to inferior) the tuber, pyramid, uvula, and nodule. The nodule is hidden deep to the uvula.

Tonsillar AVMs lie in the tonsils, which are ovoid structures on the inferomedial aspect of the cerebellar hemispheres that attach to cerebellum superolaterally through the tonsillar peduncles. The other tonsillar surfaces are free, with the inferior pole and posterior surfaces in the cisterna magna. The anterior tonsil faces the posterior medulla and is separated by the cerebellomedullary fissure. The medial tonsils face each other and are separated by the vallecula, a cleft that leads into the fourth ventricle. The ventral aspect of the superior tonsil faces the lower half of the roof of the fourth ventricle, which is formed by the tela choroidea, inferior medullary velum, and nodule. The lateral tonsil is separated from the hemisphere by the tonsillobiventral fissure.

Grading

1)
Yasargil MG. Microneurosurgery. IIIB. New York: Thieme Medical Publishers, Inc.; 1988
2)
Rhoton AL., Jr Cerebellum and fourth ventricle. Neurosurgery. 2000;47(3 Suppl):S7–27.
3)
Rodríguez-Hernández A, Kim H, Pourmohamad T, Young WL, Lawton MT. University of California, San Francisco Arteriovenous Malformation Study Project. Cerebellar arteriovenous malformations: Anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery. 2012 Dec;71(6):1111–1124.
cerebellar_arteriovenous_malformation_classification.txt · Last modified: 2019/03/09 13:12 by administrador