Microsurgical Treatment of Juxtapeduncular Angiomas Renato Da Pian, M.D., Alberto Pasqualin, M.D., and Renato Scienza, M.D. Five patients harboring juxtapeduncular angiomas were all treated by a direct microsurgical approach. Anatomic considerations, angiographic data on the feeding arteries, and related anomalies are discussed. The operating microscope and deep hypotension were very useful for the complete removal of these lesions, which were approached in most cases by a "backward" technique. Diffuse bleeding from the paraventricular area was difficult to handle. There were no postoperative deaths. At foUow-up examination, 1 patient had hemiparesis and hemianopia, 2 patients had mild visual field defects, and 2 patients had normal neurological examinations. All but one of the patients have resumed their previous occupations. It is concluded that microsurgery constitutes the best treatment for these malformations. Da Pian R, Pasqualin A, Scienza R: Microsurgical treatment of juxtapeduncular angiomas. Surg Neurol 17:16-29, 1982 Treatment of angiomas involving the medial part of the temporal lobe and extending into the ambient cistern (socalled juxtapeduncular angiomas) is controversial. Although alternative methods of treatment such as stereotactic clipping [23], embolization [14], balloon occlusion [28], and focused high-energy radiotherapy [31] have been proposed, a direct surgical approach to these lesions has been advocated by very few authors [4, 9, 20] because of the difficulties associated with this critical location. In the present report we describe our experience with juxtapeduncular angiomas in 5 patients, all radically resected by a microsurgical technique; there was no mortality and there was acceptable morbidity. Material From May, 1979, to October, 1980, 5 patients with juxtapeduncular angiomas were operated on by one of us (R. D. P. ). They constitute 4% of the 126 patients with arteriove- From the Department of Neurosurgery, Verona City Hospital, Verona, Italy. Address reprint requests to Prof. R. Da Plan, Dipartimento di Neurochirurgia, Istituti Ospitalieri, 37100 Verona, Italy. Key words: juxtapeduncular angiomas; microsurgery; deep hypotension; paraventricular bleeding. nous malformations (AVM) treated in our department. Four patients were male and 1 female; their ages ranged from 19 to 43 years. History in all patients included a subarachnoid hemorrhage, in 2 patients associated with intracerebral hematoma and in 1 patient with epilepsy. As shown in the Table, 4 malformations were on the right and 1 on the left. According to the classification of Mingrino [15], 2 arteriovenous malformations were large, extending into the temporal horn, and 3 were of medium size (maximum diameter, 2 to 5 cm). In all patients, feeding vessels were branches of the posterior cerebral artery, with its inferior temporal and posterolateral choroidal branches, and in 2 patients the anterior choroidal artery also contributed. The posterior cerebral artery originated directly from the carotid artery (fetal type) in 2 patients. Venous drainage was directed medially in 4 patients with frequent dilatation of the vein of Galen and laterally in 4 patients. Computed tomographic (CT) scan with and without enhancement was routinely used for correct localization of the angioma and for documentation of the hemorrhage and mass effect. On preoperative examination, 3 patients had no deficits, 1 patient was slightly confused, and only 1 patient exhibited a right hemiparesis. There were no postoperative deaths. Postoperative angiography demonstrated complete exclusion of the AVM in all patients. At discharge, severe disability was noted only in the patient who had had right hemiparesis, dysphasia, and hemianopia. Hemianopia was noted in 2 patients, one associated with minimal hemiparesis. Two patients had normal neurological examinations. Two to fifteen months after operation, 4 patients are working full-time; 1 has not yet resumed his previous occupation because of hemiparesis and dysphasia. In the patient with a previous history of epilepsy, and at present under anticonvulsant therapy, convulsions have not recurred. Anatomic and Angiographic Considerations These AVMs are all located in the medial and inferior portion of the temporal lobe, involving the parahippocampal gyms, the hippocampus, and not infrequently the temporal horn of the lateral ventricle, as shown in Figure 1. They sit above the tentorium and extend into the cisterna ambiens through the tentorial notch, in close relationship with the upper brainstem and especially with the cerebral peduncles. 16 0090-3019/82/010016-14501.25 O 1981 by Little, Brown and Company (Inc.) Da Pian et al: Juxtapeduncular Angiomas 17 Summary of Cases Patient No. Patient Sex, Age (yr) 1 M, 28 SAH; mild right hemiparesis 2 M, 43 3 Signs & Symptoms Side/Size; Other Findings Duration of Operation (hr) Hypotension (hr)/ Blood (ml) Feeders Draining Veins Left/large; left temporal & intraventricular hematoma Fetal PCA, AChA Vein of Galen, petrosal sinus 7 3/2,500 SAH, epilepsy, confusion Right/large Fetal PCA 2/1,500 F, 27 2 SAHs Right/medium Inferior temporal, PLC arteries 4 M, 31 SAH Right/medium Inferior ternporal, PLC, AChA Vein of Galen, 9 superior sagittal & lateral sinuses Vein of Galen, 6 lateral & petrosal sinuses Vein of Galen, 10 basal vein 5 M, 19 SAH, mild confusion Right/medium; right ternporal & intraventricular hematoma Inferior temporal, PLC arteries Lateral & sphenoidal sinuses 7 2/1,200 3/2,000 2/1,200 Postoperative Course Worsening of paresis, lasting hemianopia, transient dysphasia Lasting hemianopia, transient hemiparesis Uneventful Lasting hemianopia, transient hemiparesis Uneventful SAH = subarachnoidhemorrhage;PCA = posteriorcerebralartery; AChA = anteriorchoroidal artery;PLC = posterolateralchoroidalartery. The main feeding vessel to these angiomas (Fig. 2) is the posterior cerebral artery (PCA) through: (1) the inferior temporal arteries, arising as a single trunk or as separate branches (hippocampal, anterior, middle, and posterior temporal arteries), feeding the inferomedial part of the temporal lobe; and (2) 1 to 9 lateral posterior choroidal arteries passing through the choroidal fissure and feeding the region surrounding the temporal horn of the lateral ventricle and the choroid plexus of the temporal horn. The other vessel supplying these angiomas is the anterior choroidal artery, with terminal branches that anastomose with the lateral posterior choroidal arteries in the choroid plexus of the temporal horn (Fig. 2). Anomalies of the posterior cerebral artery are relatively common, particularly originating directly from the carotid artery (fetal type) with absent or poorly developed precommunicating segments. The venous drainage of these angiomas is mainly toward the deep venous system and to a minor extent toward the lateral, sigmoid, and cavernous sinuses and cortical veins. Surgical Technique A temporal approach was adopted in all patients, as suggested by Drake [3, 5], for aneurysms of the basilar and posterior cerebral arteries. The temporal flap was extended anteriorly to reach the lesser sphenoid wing and to gain better exposure of the anterior portion of the temporal lobe. The veins draining toward the lateral sinus were spared when possible, especially on the left. In our patients, it was never necessary to incise the tentorium. The brain was relaxed by osmotic agents and by opening the ambient cistern. The operating microscope was particularly useful in the narrow operative field with limited space for surgical maneuvers. In some patients, as suggested by Drake and Amacher [5], it was convenient to remove part of the parahippocampal gyrus overlying the angioma using suction--a technique very similar to the removal of the gyrus rectus for approaching anterior communicating artery aneurysms. In all patients the posterior cerebral artery was very deep, hidden in the choroidal fissure. Also, the presence of a fetal type posterior cerebral artery caused further difficulty in identifying the single feeding vessels [18]. The venous drainage, often extensive and overlying the angioma itself, was approached by inducing deep hypotension, allowing closure of draining veins before the feeding arteries were occluded. This "backward" technique was without complications. Deep hypotension and the operating microscope were extremely useful in the progressive closure of the feeding vessels by clipping and by normal or bipolar coagulation. Repeated hemorrhages during dissection of the often numerous lateral choroidal branches, as well as diffuse bleeding from the paraventricular area especially at the end of operation, were difficult and often caused a delay of hours for the complete removal of the malformation. During deep hypotension induced by sodium nitroprusside [2], blood pressure values were maintained at 18 Surgical Neurology Vol 17 N o 1 January 1982 i. . . . . . . . . . . . . . . . I ,'\/ i _ V l --_ J... j ,/ ! . t'- P. C.A.,, / /'IP.Ca.A. / Fig. 1. Location of juxtapeduncular angzo~,u2s in a vertical section. C h P l = ch(rroid plexus of the temporal horn; P C A = posterior cerebral artery; M P C h A = posteromedial choroidal artery; PhGy = parahippocampal gyrus; H = hippocampus; T H = temporal horn of the lateral ventricle; B = brainstem. The area of A V M is indicated by the, dashed circle. :/ il i¸ ! iI /i i OP £1 f "" .... -- J T.L /1_, f AE4A \ I / F s'/ CP -frA \ ,14PE.,( A / % ,.~ ' i LPe.4A~ i i,. i \~) C' f 7¸¸¸¸¸¸ ¸¸ / f z .cc PO L/ ii Fig. 2. Vascular supply to juxtapeduncular angiomas in horizontal section. O P = optic chiasm; I C = internal carotid artery; A C A = anteri{rr cerebral artery; M C A = middle cerebral artery; A C h A = anterior choroidal artery; T L = temporal lobe; T H = temporal horn of the lateral ventricle; C h =- choroid plexus of the temporal horn; B = basilar fundus; 3 r d = oculomotor nerve; P C A = posterior cerebral artery; C P = cerebral peduncle; I T A = inferior temporal artery( ies) ; M P C h A = posteromedial choroidal artery; L P C h A = posterolateral choroidal arteries; 4 t h = trochlear nerve; C a = calcarine artery; P O = parietooccipital artery; S p C C = splenium of corpus callosum. The area of A V M is indicated by the d a s h e d c i r c l e . 19 20 Surgical Neurology Vol 17 No 1 January 1982 A C B D about 50 mm Hg systolic in all patients; the total dose of the drug never exceeded 2 milligrams per kilogram of body weight, even when deep hypotension was maintained for hours. It should be stressed that all the surgical procedures lasted six to ten hours, and each patient required more than 1 liter of blood. Fig. 3. Patient I. Left carotid an~ograms. (A) Anteroposterior and (B) lateral views: huge AVM of the left mesial temporal lobe fed by a fetal posterior cerebral artery and by the anterior choroidal artery. ( C) Venous drainage toward the vein of Galen and petrosal sinus. (D) Postoperative view: an~oma removed with marked spasm of posterior cerebral artery. Case Reports poral hematoma. Ten days after a verified subarachnoid hemorrhage, he was admitted to our department on March 2 I, 1979, with marked stiffness of the neck and a mild right hemiparesis. A left carotid angiogram (Fig. 3) showed a Patient i A 28-year-old man had been operated on in another hospital at the age of 8 years for the evacuation of a left tem- Da Pian et al: Juxtapeduncular Angiomas huge AVM involving the left mesial temporal lobe, fed by a fetal type posterior cerebral artery and by the anterior choroidal artery; the venous drainage was toward the vein of Galen and the petrosal sinus. A C T scan showed a left temporal hematoma with intraventricular hemorrhage. After the insertion of a ventriculoatrial shunt for control of progressive ventricular dilatation, the patient was operated upon six weeks after admission, at which time he was still hemiparetic. After a left subtemporal approach, the angiomatous vessels appeared on the inferomedial surface of the temporal lobe. Before the angioma was approached, the posterior cerebral artery was exposed in its anterior part, showing an altered anatomic relationship to the basilar fundus (the precommunicating tract was absent) and to the cerebral peduncle. The feeders to the malformation were numerous: by approaching the angioma at its edges, these vessels were progressively closed. The main trunk of the posterior cerebral artery could be seen until its entrance into the angioma, and then not distally. The venous drainage, both lateral and medial, was occluded. Medially, the angioma was adherent to the cerebral peduncle, but could be dissected free. The complete removal of the lesion took almost three hours, and was performed with the patient under continuous deep hypotension and with adequate control of bleeding. A diffuse hemorrhage from the ventricular walls, after removal of the angioma, constituted a very difficult problem; however, hemostasis was finally achieved. After a difficult postoperative course, the patient was discharged three weeks after the operation with dysphasia, severe right hemiparesis, and right homonymous hemianopia. Subsequent angiography (Fig. 3D) showed a marked spasm of the posterior cerebral artery. On examination fifteen months later after three revisions of the shunt system, the patient showed improvement from the right hemiparesis, persistence of the hemianopia, and disappearance of the dysphasia; nevertheless, he has not yet resumed his former occupation. Patient 2 A 43-year-old man had suffered a mild subarachnoid hemorrhage fifteen years before, and for more than seventeen years had had a history of uncinate convulsions that responded little to medical therapy. After a grand mal seizure, he was admitted to another hospital, where a right carotid angiogram (Fig. 4) showed a large AVM of the right mesial temporal lobe, fed by a fetal posterior cerebral artery, with huge veins draining medially to the vein of Galen and laterally to the lateral and superior sagittal sinuses. On admission to our department on July 2, 1979, the patient was found to be slightly confused. A contrast-enhanced CT scan (Fig. 5) showed the location of the angioma within the temporal lobe and in the temporal horn, with medial extension to the ambient cistern and with dilated venous drainage. Three weeks after admission, the patient was op- 21 erated upon while he was still in a slightly confused condition. By a right frontotemporal approach, the sylvian fissure and the undersurface of the temporal lobe, covered by draining veins, were exposed. After removal of the anterior tip of the temporal lobe and occlusion of the venous drainage toward the sphenoidal sinus, the angioma could be approached deeply. After the large fetal posterior cerebral artery was found more medial and deeper than normal, the feeding vessels to the angioma were progressively closed. Finally, the large posterior cerebral artery, apparently terminating in the angioma, was temporarily closed by a clip, thus reducing the size of the angioma. Further exploration using the microscope allowed identification of the distal trunk of the posterior cerebral artery, from which a "haircomb" of vessels emerged to feed the angioma; by closing these vessels, it was possible to remove the clip on the posterior cerebral artery and to excise the angioma completely, sparing the posterior cerebral artery. The angioma extended into the temporal horn and reached the cerebral peduncle. Three weeks later the patient experienced much improvement from a left hemiparesis and homonymous hemianopia, which developed during the postoperative course. A subsequent angiogram (Fig. 4D) showed preservation of the posterior cerebral artery and complete exclu. sion of the angioma. On examination eleven months later, the patient still had a visual deficit, whereas the hemiparesis had almost completely disappeared. He has now resumed his previous occupation and according to relatives has shown a significant psychological improvement since the operation. It is interesting to note that the patient has suffered no further uncinate convulsions, even though the anticonvulsant therapy is the same as before the operation (phenobarbital and carbamazepine). Patient 3 A 27-year-old female teacher was admitted to another hospital after two mild episodes of verified subarachnoid hemorrhage. Four-vessel angiography (Fig. 6) showed a medium-sized right juxtapeduncular angioma involving the parahippocampal gyrus, with arterial supply from the posterior cerebral artery through inferior temporal and posterolateral choroidal branches. The venous drainage was toward the vein of Galen, and toward the petrosal and lateral sinuses. On admission to our department on March 3, 1980, the patient had no neurological deficits. A C T scan confirmed the location of the angioma. One week after admission, the patient was operated upon. The parahippocampal gyrus was exposed through a right temporal craniotomy: the angioma involved this gyrus and extended into the ambient cistern adherent to the cerebral peduncle. The trunk of the posterior cerebral artery was exposed; the inferior temporal and posterolateral choroidal branches, departing from the trunk itself, were all occluded near the malformation. To dissect the angioma from the 22 Surgical Neurology Vol 17 No 1 January 1982 A C D peduncle, it was necessary to close a large medially draining vein, thus exposing the underlying last feeders; after their closure, the angioma slackened and could be removed after closure of the remaining medially-draining veins. Hemostasis was particularly difficult to maintain in the area of the temporal horn of the lateral ventricle. After an uneventful postoperative course, the patient was discharged one week later with no deficit. At a subsequent examination eight months later, the patient had resumed teaching and was free of disturbances. Patient 4 A 31-year-old male teacher was admitted to another hospital after a verified subarachnoid hemorrhage. A complete angiographic study (Fig. 7) showed a medium-sized right Fig. 4. Patient 2. Right carogd an~ograms. (A) Anteroposterior and (B) lateral views: large AVM of the right mesial temporal lobe (note marked hypertrophy of fetal posterior cerebral artery). ( C) Extensive venous drainage toward the vein of Galen and the lateral sinus. ( D) Postoperative view, showing complete exclusion of the AVM (note the angulated clip parallel to the posterior cerebral artery). juxtapeduncular angioma involving the hippocampal gyms and fed by the posterior cerebral artery through inferior temporal and posterolateral choroidal branches and by the anterior choroidal artery. The venous drainage was toward the vein of Galen and the basal vein. A CT scan (Fig. 8) confirmed the location of the angioma, extending into the ambient cistern. On admission to our department on May Da Plan et al: Juxtapeduncular Angiomas 23 A 5, 1980, the patient had a normal neurological examination. One week later, he was operated upon. After a right temporal craniotomy, the hippocampal gyms, covered with angiomatous vessels, was exposed. The posterior cerebral artery was identified in the choroidal fissure, and numerous branches departing from its trunk and feeding the angioma were progressively closed inside the hippocampal gyrus. It was necessary to close a large draining vein to expose other feeders to the angioma. The identification of these vessels was particularly difficult because of a severe hemorrhage, even though the patient was under hypotension. After control of the hemorrhage and closure of the feeding vessels and of the medially draining veins, the angioma could be removed by dissection of its points of adherence to the brainstem and to the cerebellum. The surgical procedure in this case was particularly difficult because of the severity of the hemorrhage. A mild left hemiparesis that developed in the early postoperative course had disappeared by discharge two weeks later; a left homonymous hemianopia persisted unchanged. Subsequent angiography (Fig. 7D) showed complete exclusion of the angioma with preservation of the posterior cerebral and anterior choroidal arteries. At an examination six months later, the patient had resumed his previous activity. Patient 5 B Fig. 5. Patient 2. C T scan with contrast enhancement: ( A) right mesial temporal angioma extending to the ambient cistern; ( B) dilated venous drainage. A 19-year-old male student, with a long history of severe recurrent headaches, was admitted to our department on September 22, 1980, two days after a verified subarachnoid hemorrhage. On admission, he had marked stiffness of the neck and slight confusion. A CT scan showed a right temporal hematoma with intraventricular hemorrhage. A right vertebral angiogram (Fig. 9) showed a medium-sized AVM involving the parahippocampal gyms, fed by the posterior cerebral artery through the inferior temporal, posterolateral choroidal, and parietooccipital arteries. The venous drainage was toward the lateral and sphenoidal sinuses. After reabsorption of the intraventricular hemorrhage, the patient was operated upon one month later, with no neurological deficits. By a right temporal approach, the red veins draining to the sphenoidal sinus were closed before the angioma was approached. The parahippocampal gyms, covered by angiomatous tissue, and the posterior cerebral artery, hidden in the choroidal fissure, were exposed. Because of the presence of the hematoma, the undersurface of the temporal lobe was incised and the temporal horn, filled with clots, was exposed; the angioma extended to the medial walls of the temporal horn. After closure of the numerous feeding vessels from the posterior cerebral artery, the venous drainage toward the lateral sinus became dark. The whole angioma was then removed together with the parahippocampal gyms after dissection from the cerebral peduncle. After an uneventful postoperative course, the patient 24 Surgical Neurology Vol 17 No 1 January 1982 A C D Fig. 6. Patient 3. Vertebral angiograms. (A) Anteroposterior and (B) lateral views {~fright juxtapeduncular angioma. ( C) Venous drainag~e toward the vein of Galen and the petrosal and lateral sinuses. (D) Postoperative view showing exclusion of the AVM. Fig. 7. Patient 4. Vertebral angiograms. (A) Anteroposterior and (B) lateral views of right juxtapeduncular angioma. ( C) Venous drainage toward the vein of Galen and basal vein. (D) Postoperative view, with angioma completely excluded (note the numerous clips and the preservation of a patent posterior cerebral artery). 5~ 26 SurgicalNeurology Vol 17 No 1 January 1982 was discharged two weeks after the operation with a normal neurological examination. A subsequent angiogram on November 6, 1980 (Fig. 9C), showed the complete exclusion of the AVM. On examination two months later the patient showed no residual disturbances and had been attending school regularly. Discussion A B Fig. 8. Patient 4. C T scan with contrast enhancement. (A) Right juxtapeduncular angioma extending to the ambient cistern; (B ) dilated venous drainage. Juxtapeduncular angiomas are rare; our experience supports the findings of other authors who claim that they constitute only about 3 to 4% of cerebral AVMs [4, 19]. Their treatment is controversial because of the difficulties presented by their surgical removal. These lesions have rarely been operated on in the past [20], and with poor results. More recently, direct surgical treatment has been advocated by a few authors [4, 9] on the basis of more encouraging experiences. However, most reports still advise alternative methods of treatment, such as embolization [ 13, 14, 16, 26, 27, 30], stereotactic clipping [10, 23, 24], cryotherapy [37, 38], focused high-energy radiotherapy [8, 11, 31, 32], and balloon occlusion [28], even though none of these methods is free from risk. Even nonoperative treatment has been proposed in view of the relatively low incidence of rebleeding [33, 35, 36]. However, complete surgical obliteration of the lesion is undoubtedly the best type of treatment when coupled with the prospect of low morbidity. In this connection, hemianopia should be considered a minor concern when evaluating the possibility of a fatal hemorrhage when left untreated. Even with surgical closure of the main trunk of the posterior cerebral artery, the development of a neurological deficit is not always the rule: other authors [5, 7] have reported permanent occlusion of this artery without consequence to the patient. It should be pointed out that the vascularization of the calcarine cortex is far from exhibiting a uniform pattern; collateral flow may well nourish this area in the absence of supply from the posterior cerebral artery [29]. Unfortunately, this was not the case in our first patient, in whom the neurological impairment after spasm of the posterior cerebral artery was severe, possibly because of the high output of the fetal posterior cerebral artery. As regards anatomic considerations about the operability of these angiomas, the possibility of dissection from the surface of the brainstem should be stressed. In fact, even if these angiomas extend into the cisterna ambiens, in our experience they are not closely adherent to the brainstem. These angiomas may sometimes be difficult to differentiate from mesencephalic angiomas in which surgical treatment is not clearly indicated, as pointed out by Drake [4]. In our experience, the operability of juxtapeduncular angiomas is not related to the direction of the venous outflow: whereas a medially-directed venous drainage is regarded by some authors as indicating inoperability [9, 20], it did not prevent excision of the angiomas in our patients. Da Plan et al: Juxtapeduncular Angiomas 27 C A B Fig. 9. Patient 5. Vertebral angiograms: (A) anteroposterior and (B) lateral views of right juxtapeduncular an~oma. ( C ) Postoperative view showing exclusion of AVM. The precise identification of the tentorium, achieved by CT scan [17], is important for preoperative localization of the AVM above or below the tentorium. In all of our patients, the lesion was entirely supratentorial or paratentorial, which facilitated a direct subtemporal approach. As shown by our 2 patients, anomalies of the posterior cerebral artery are common when dealing with large AVMs fed by this artery. The fetal type posterior cerebral artery, originating directly from the carotid artery, has been widely described elsewhere [18, 25, 39]. This anomaly causes a major alteration of the normal anatomic relations between this artery, the brainstem, and the inferomedial part of the temporal horn. Consequently, identification and dissection of the branches departing from the main trunk of the posterior cerebral artery present considerable difficulties, as shown in our first patient. The normal rich vascularization of the area surrounding the temporal horn supplied by the anterior and posterolateral choroidal arteries is even more luxuriant in the presence of a juxtapeduncular angioma. As pointed out by others [6], the lateral posterior choroidal arteries can be numerous--as many as 9 in a normal hemisphere. The difficulty in handling hemorrhages from these tiny, sparse vessels cannot be overemphasized. Moreover, diffuse varicosities on the ventricular walls, a cause of annoying bleeding, are found not only in these angiomas, but also in any angioma extending to the ventricular system anywhere. Our experience with other patients [1] suggests that this problem arises from the extensive anastomoses between the 28 Surgical Neurology Vol 17 No 1 January 1982 t e r m i n a l branches of the various choroidal a r t e r i e s - - i n the lateral, third, a n d fourth v e n t r i c l e s - - a s illustrated by R h o t o n and colleagues [6, 22, 25, 39]. These anastomoses are certainly engorged in the presence of angiomatous tissue in proximity; it is also possible that, in these conditions, the capillary walls prove extremely fragile to e v e n m i n i m a l m e c h a n i c a l m a n i p u l a t i o n , thus e x p l a i n i n g the diffuse paraventricular bleeding. As to the value of deep h y p o t e n s i o n for surgical removal of A V M s , our previous experience [1] was confirmed by these 5 cases. A p a r t from better control of bleeding, especially valuable in these highly vascularized lesions, deep h y p o t e n s i o n was useful in our "backward" approach, i.e., initial occlusion of the d r a i n i n g veins from the malformation. In fact, during h y p o t e n s i o n , closure of the slackened veins does n o t cause swelling of the a n g i o m a as it does u n d e r n o r m o t e n s i o n . T h e "backward" t e c h n i q u e , suggested by others before [12, 21, 34], facilitates the approach to the individual feeding vessels, easily identified after partial exclusion of the v e n o u s drainage. T h e operating microscope proved necessary in the surgical t r e a t m e n t of these lesions, w h i c h are located deep in the brain, thus allowing only a limited field for surgical m a n e u vers. In conclusion, with the use of m o d e r n operative a n d anesthesiological facilities, surgical t r e a t m e n t of juxt a p e d u n c u l a r angiomas has become n o t only possible b u t e v e n advisable in view of the low morbidity w h e n compared to the risks of alternative or conservative t r e a t m e n t . The authors express their thanks to Ms. Gillian M. Hammond for her assistance in the preparation of the manuscript. References 1. Da Pian R, Pasqualin A, Scienza R, Vivenza C: Microsurgical treatment of ten arteriovenous malformations in critical areas of the cerebrum. J Microsurg 1:305-320, 1980 2. Da Plan R, Pasqualin A, Scienza R, Vivenza C, Malesani GC: Deep controlled hypotension with sodium nitropmsside in the surgical treatment of intracranial arterial aneurysms. J Neurosurg Sci 23:109-120, 1979 3. Drake CG: Further experience with surgical treatment of aneurysms of the basilar artery. J Neurosurg 29:372-392, 1968 4. 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Perret G, Nishioka H: Report on the Cooperative Study of lntracranial Aneurysms and Subarachnoid Hemorrhage. Arteriovenous malformations. An analysis of 545 cases of cranio-cerebral arteriovenous malformations and fistulae reported to the cooperative study. J Neurosurg 25:467-490, 1966 20. Pertuiset B, Sachs M, Guyot JF: Les an~vrysmes art~rioveineux des parois juxta-p&tonculaires de la fente de Bichat. Presse Med 71:2341-2342, 1963 21. Pertuiset B, Sichez JP: The backward technique in the total excision of cerebral arteriovenous malformations: experience with 86 cases, in Wiillenweber R et al (eds): Advances in Neurosurgery. Berlin: Springer-Verlag, 1978, Vol 6, pp 148-153 22. Rhoton AL Jr, Fujii K, Fradd B: Microsurgical anatomy ofthe anterior choroidal artery. Surg Neurol 12:171-187, 1979 23. Riechert T: Stereotactic treatment of central angiomas, in Pia HW, Gleave JRW, Grote E, Zierski J (eds): Cerebral Angiomas. Advances in Diagnosis and Therapy. Berlin: Springer-Verlag, 1975, pp 129-135 24. Riechert T, Mundinger F: Combined stereotaxic operation for treatment of deep-seated angiomas and aneurysms. J Neurosurg 21:358363, 1964 25. Saeki N, Rhoton AL Jr: Microsurgical anatomy of the upper basilar artery and the posterior circle of Willis. J Neurosurg 46:563-578, 1977 26. Sano K, Jimbo M, Saito I, Basugi N: Artificial embolization of inoperable angioma with polymerizing substance, in Pia HW, Gleave JRW, Grote E, Zierski J (eds): Cerebral Angiomas. Advances in Diagnosis and Therapy. Berlin: Springer-Verlag, 1975, pp 222-229 27. Seeger W: The artificial embolization of inoperable angiomas, in Pia HW, Gleave JRW, Grote E, Zierski J (eds): Cerebral Angiomas. Advances in Diagnosis and Therapy. Berlin: Springer-Verlag, 1975, pp 213-221 28. Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:125-145, 1974 29. Smith CG, Richardson WF: The course and distribution of the arteries supplying the visual (striate) cortex. Am J Ophthalmol 61:1391-1396, 1966 Da Plan et al: Juxtapeduncular Angiomas 30. Stein BM, Wolpert SM: Surgical and embolic treatment of cerebral arteriovenous malformations. Surg Neurol 7:359-369, 1977 31. Steiner L: Radiosurgeryfor arteriovenous malformations, presented at the Italian Neurosurgical Society, Rome, April, 1978 32. Steiner L, Leksell L, Forster DMC, Greitz T, Backlund EO: Stereotactic radiosurgery in intracranial arterio-venous malformations. Acta Neurochir (Wien).Suppl 21:195-209, 1974 33. Svien HJ, Mc Rae JA: Arteriovenous anomalies of the brain. Fate of patients not having definitive surgery. J Neurosurg 23:23-28, 1965 34. T~SnnisW, Walter W: Die Indikation mr Totalextirpation der intrakraniellen arteriovenosen Angiome. Dtsch Z Nervenheilk 186: 27%298, 1964 35. Troupp H, Marttila I, Halonen V: Arteriovenous malformations of 29 the brain. Prognosis without operation. Acta Neurochir (Wien) 22:125-128, 1970 36. Trumpy IH, Eldevik P: lntracranial arteriovenous malformations: conservative or surgical treatment? Surg Neurol 8:171-175, 1977 37. Walder HAD: Application of cryotherapy in arterio-venous aneurysms. An experimental and clinical study. J Neurol Neurosurg Psychiatry 34:105, 1971 38. Walder HAD: Freezing arteriovenous anomalies in the brain, in Pia HW, Gleave JRW, Grote E, ZierskiJ (eds): Cerebral Angiomas. Advances in Diagnosis and Therapy. Berlin: Springer-Verlag, 1975, pp 183-193 39. Zeal AA, Rhoton AL Jr: Microsurgical anatomy of the posterior cerebral artery, l Neurosurg 48:534-559, 1978 Book Review Clinical Neuro-ophthalmology, ed. 2 By Bryan Ashworth and fan Isherwood, Oxford, St. Louis, BlackweU Scientific Publications, 1981 298 pp., $86.00 Reviewed by J. Lawton Smith, Miami, Florida This text is by Dr. Ashworth, neurologist at the University of Edinburgh, and Dr. Isherwood, Professor of Radiology at the University of Manchester, England; fundus illustrations were provided by Dr. Emanuel Rosen of the Manchester Royal Eye Hospital. It is probably appropriate to begin by considering the positive features of the book. It is printed on high-quality paper, has an attractive appearance, size, and format, and the printing and illustrations are nicely reproduced. In my opinion, by far the best chapter in the book is chapter 8, "Radiology." T h e reproductions of the roentgenograms are good, the chapter is well written, and the section on computed tomography is reasonably up-to-date. Chapter 6, "Retinal Photography," is also good, and there is a nice series of color plates of various optic nerve problems. C h a p t e r 3, "History," is well written, including such pertin e n t statements as, "The presence of relatives avoids the n e e d to go over the story again, and it is always worth asking at the end if they have anything to add." It must be added, however, that there are significant negative factors about this text that should be mentioned. T h e price is probably justified when one considers that there are 13 pages of colored illustrations in the book. There are, however, many points that are either inadequate or in error. For example, on page 13 a pinhole "1 ram. in diameter" is recommended. In my experience, this is much too small. Again, concerning the pinhole test, the statement is made, "If the acuity is worse there may be a macular lesion." This does not mention the fact that any patient with opacity in the media, as well as a central scotoma, will also see poorer with a pinhole aperture than without it. O n page 16 the statement, "If the diplopia is vertical, proptosis should be sought," certainly appears cryptic to me. Serological tests for syphilis usually mention the Wassermann reaction, and I did not see any mention of the F T A . A B S (fluorescent treponemal antibody absorbed) test in the text. Many would disagree with the statement on page 21 that, "The perimeter is of limited value in neurological work . . . . " Finger wiggling is advocated on confrontation on page 23, and many would think that could be improved. O n page 23 the statement is made, " W h e n a structural lesion is visible by ophthalmoscopy or there is opacity of the cornea, lens or media the value of recording the subjective field is limited." One would certainly have to modify this statement, I believe. There are many other examples of questionable observations which limitations of space do not allow me to c o m m e n t on here. The description of the afferent pupil on page 12 is certainly open to question. T h e statement, "Constriction, followed at once by dilatation to the previous size, is known as the afferent pupillary sign . . . . " is made without really relating the detection of an afferent pupil to the swinging flashlight test. In summary, there are enough areas of question that many ophthalmologists would find in reading this book that I should express reservations about encouraging its purchase. It might, however, serve as a worthwhile introduction for a junior medical student starting a neurosurgical or neurology rotation.