Transsylvian, Carotid-Oculomotor Triangle Approach for Resection of a Rapidly Enlarging Midbrain-Pontine Cavernous Malformation: 3-Dimensional Operative Video

2019 ◽  
Vol 17 (3) ◽  
pp. E112-E112
Author(s):  
Thomas J Sorenson ◽  
Joshua D Hughes ◽  
Giuseppe Lanzino ◽  
Leonardo Rangel Castilla
Keyword(s):  
Surgical Planning ◽  
Cavernous Malformation ◽  
Mass Effect ◽  
Sylvian Fissure ◽  
Cavernous Malformations ◽  
3 Dimensional ◽  
Postoperative Mri ◽  
Leg Weakness ◽  
Magnetic Resonance Imaging Mri ◽  
Orbital Rim

Abstract Cavernous malformations (CM) of the anterior midbrain are best reached through an orbitozygomatic (OZ) approach with removal of the orbital rim and wide Sylvian fissure dissection. Our surgical video demonstrates this approach to resect a ruptured CM in a 36-yr-old woman who presented with headaches, left face and left arm paresthesias/weakness, and right-sided partial oculomotor nerve (CN III) palsy. Initial magnetic resonance imaging (MRI) showed a midbrain CM, and the patient was managed conservatively. However, 1 wk later, she presented again with worsened left arm and leg weakness and complete CN III palsy. Seven Tesla MRI demonstrated a larger hematoma, and the CM with new mass effect and upper pons extension. The patient underwent a right modified OZ craniotomy and Sylvian fissure split under guidance of intraoperative neuronavigation and with neuromonitoring. The carotid-oculomotor triangle and the Liliequist membrane were dissected to access the midbrain, and CN III was identified and followed posteriorly to the midbrain. Confirmed with neuronavigation, a longitudinal incision of the midbrain was performed, and the CM was encountered. The hematoma and CM were debulked and removed in a piece-meal fashion, leaving hemosiderin-stained brain intact to prevent unnecessary additional damage to the midbrain. Postoperative MRI confirmed gross-total resection, and the patient's weakness recovered substantially. In this video, we demonstrate that the brainstem is no longer forbidden surgical territory, and show how the use of neuronavigation for surgical planning, positioning, and approach, in addition to the understanding of safe entry zones and meticulous microsurgical technique have made safe and effective surgery on the brainstem possible.

Transclival Approach for Resection of a Pontine Cavernous Malformation: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E413-E413
Author(s):  
Dennis London ◽  
Seth Lieberman ◽  
Omar Tanweer ◽  
Donato Pacione
Keyword(s):  
Cavernous Malformation ◽  
Case Reports ◽  
Abducens Nerve ◽  
Petrous Bone ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Lumbar Drain ◽  
Magnetic Resonance Imaging Mri

Abstract Cerebral cavernous malformations are common vascular anomalies consisting of a cluster of capillaries without intervening brain tissue.1 A variety of approaches for resection have been undertaken,2 and a handful of case reports have described the endoscopic, endonasal, transclival approach.3 We present a case of a 51-yr-old woman with lupus and hepatitis B-associated cirrhosis who presented with diplopia, dysphagia, and ataxia. She had a left abducens nerve palsy and magnetic resonance imaging (MRI) showed a left pontine cavernous malformation. After a repeat hemorrhage, she consented to surgical resection. The lesion appeared to come to the medial pontine pial surface. Tractography indicated a rightward displacement of the left corticospinal tract. Therefore, an endoscopic, transnasal, transclival approach was chosen. A lumbar drain was placed preoperatively. The clivus and ventral petrous bone were drilled using the vidian canal to help identify the anterior genu of the petrous carotid artery. The clival dura was opened, revealing the abducens nerve exiting the ventral pons. The cavernoma was visible on the surface lateral to the nerve. It was removed using blunt dissection and the remaining cavity inspected. The skull base was reconstructed using an abdominal dermal-fat graft and Alloderm covered by a nasoseptal flap. Postoperatively she had transient swallowing difficulty. The lumbar drain was kept open for 5 d. Cerebrospinal fluid (CSF) leak was ruled out using an intrathecal fluorescein injection. She was discharged home, but presented 2 wk postoperatively with aseptic meningitis, which was treated supportively. Postoperative imaging did not show residual cavernoma.

Surgical Resection of a Cavernous Malformation of the Anterior Perforated Substance: 2-Dimensional Operative Video

2018 ◽  
Vol 17 (2) ◽  
pp. E64-E64
Author(s):  
Alejandro Enriquez-Marulanda ◽  
Abdulrahman Y Alturki ◽  
Luis C Ascanio ◽  
Ajith J Thomas ◽  
Christopher S Ogilvy
Keyword(s):  
Optic Tract ◽  
Brain Magnetic Resonance Imaging ◽  
Mass Effect ◽  
Brain Structures ◽  
Acute Onset ◽  
Elective Resection ◽  
Cavernous Malformations ◽  
Patient Consent ◽  
Magnetic Resonance Imaging Mri ◽  
The Right

Abstract Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

Resection of a Lumbar Intradural Extramedullary Schwannoma: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (5) ◽  
pp. 640-640 ◽  
Author(s):  
Simone E Dekker ◽  
Chad A Glenn ◽  
Thomas A Ostergard ◽  
Mickey L Smith ◽  
Brian D Rothstein ◽  
...  
Keyword(s):  
Back Pain ◽  
Treatment Options ◽  
Tumor Resection ◽  
Sensory Nerve ◽  
En Bloc ◽  
3 Dimensional ◽  
Postoperative Mri ◽  
Intradural Extramedullary ◽  
Magnetic Resonance Imaging Mri ◽  
Dural Opening

Abstract This 3-dimensional operative video illustrates resection of a lumbar schwannoma in a 57-yr-old female who presented with right lower extremity numbness, paresthesias, as well as a long history of lower back pain with rest. On magnetic resonance imaging (MRI), there was evidence of an intradural extramedullary enhancing lesion at L5, nearly completely encompassing the spinal canal. This video demonstrates the natural history, treatment options, surgical procedure, risks, and complications of treatment of these types of tumors. The patient underwent a posterior lumbar laminectomy with a midline dural opening for tumor resection. The tumor was encountered intradurally and electromyography recording confirmed that the tumor arose from a lumbar sensory nerve root. The sensory root was then divided and the tumor was then removed. The mass was removed en bloc and histopathologic analysis was consistent with a schwannoma. Postoperative MRI demonstrated gross total resection of the patient's neoplasm with excellent decompression of the spinal cord. The patient had an uneventful postoperative course with full recovery and complete resolution of her back pain and leg paresthesias.

scholarly journals Microsurgical resection of an inferior cerebellar peduncle cavernous malformation: 3-Dimensional operative video

2019 ◽  
Vol 1 (1) ◽  
pp. V22
Author(s):  
Guilherme H. W. Ceccato ◽  
Rodolfo F. M. da Rocha ◽  
Julia Goginski ◽  
Pedro H. A. da Silva ◽  
Gabriel S. de Fraga ◽  
...  
Keyword(s):  
Cavernous Malformation ◽  
Neurophysiological Monitoring ◽  
Cavernous Malformations ◽  
3 Dimensional ◽  
Initial Symptoms ◽  
Intimate Relation ◽  
Microsurgical Resection ◽  
Cerebellomedullary Fissure ◽  
Cerebellar Peduncle ◽  
Inferior Cerebellar Peduncle

Brainstem cavernous malformations are especially difficult to treat because of their deep location and intimate relation with eloquent structures. This is the case of a 26-year-old female presenting with dizziness, dysmetria, nystagmus and unbalance. Imaging depicted a lesion highly suggestive of a cavernous malformation in the left inferior cerebellar peduncle. Following a suboccipital midline craniotomy, the cerebellomedullary fissure was dissected and the lesion was identified bulging the surface. The malformation was completely removed with constant intraoperative neurophysiological monitoring. The patient presented improvement of initial symptoms with no new deficits. Surgical resection of brainstem cavernous malformations can be successfully performed, especially when superficial, using the inferior cerebellar peduncle as an entry zone.The video can be found here: https://youtu.be/-GGZe_CaZnQ.

Interhemispheric Contralateral Transfalcine Approach for Subparacentral Arteriovenous Malformation: 3-Dimensional Operative Video

2021 ◽  
Author(s):  
Matías Baldoncini ◽  
Alvaro Campero ◽  
Sabino Luzzi ◽  
Juan F Villalonga
Keyword(s):  
Right Hemisphere ◽  
Vascular Lesion ◽  
Neurological Deficits ◽  
3 Dimensional ◽  
Postoperative Mri ◽  
Drainage Vein ◽  
History Of ◽  
Magnetic Resonance Imaging Mri ◽  
Superior Longitudinal Sinus ◽  
The Right

Abstract Neurovascular procedures along the interhemispheric fissure harbor unique features differentiating them from those arteriovenous malformations (AVMs) located at the lateral surface of the brain.1-4  The aim of this 3-dimensional operative video is to present a microsurgical resection of an AVM in a subparacentral location, operated through an interhemispheric contralateral transfalcine approach.1,3,5  This is a case of a 29-yr-old female, with headaches and history of seizures. The patient presented an interhemispheric bleeding 6 mo before the surgery. The magnetic resonance imaging (MRI) showed a vascular lesion located on the medial surface of the right hemisphere at the confluence between the cingulate sulcus and its ascending sulcus. In the cerebral angiography, a right medial AVM was observed, receiving afference from the right anterior cerebral artery and draining to the superior longitudinal sinus. The patient signed an informed consent for the procedure and agreed with the use of her images and surgical video for research and academic purposes.  The patient was in a supine position, and a left interhemispheric contralateral transfalcine approach was performed,1-3 a circumferential dissection of the nidus, and, finally, the AVM was resected in one piece.  The patient evolved without neurological deficits after the surgery. The postoperative MRI and angiography showed a complete resection of the AVM.  In the case presented, to avoid exposing the drainage vein first and to use the gravity of the exposure, the contralateral transfalcine interhemispheric approach was used,1,2 which finally accomplished the proposed objectives.

scholarly journals Left Interhemispheric Craniotomy for Resection of Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E154-E154
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Lateral Ventricle ◽  
Cavernous Malformation ◽  
Third Ventricle ◽  
Video Recording ◽  
Mass Effect ◽  
Cavernous Malformations ◽  
Transcallosal Approach ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Surgical Field

Abstract Thalamic cavernous malformations pose variable surgical challenges given that the location and size of the lesion often determine the approach surgical trajectory. The patient in this case has a large thalamic cavernous malformation that results in a mass effect on the third ventricle and directly abuts the lateral ventricle. A small interhemispheric craniotomy is performed to allow for an anterior interhemispheric transcallosal approach to the lesion. The lateral ventricle is accessed, and the septum is removed to enhance visualization of the surgical field. A small rim of normal parenchyma on the lateral margin of the thalamus is transgressed, and the cavernous malformation is entered. The lesion is removed in a piecemeal manner. Use of counter traction assists with the piecemeal removal. The lighted suction is critical during inspection and manipulation of the lesion within the resection cavity given the limited lighting deep within the cavity. The lesion was removed completely, and postoperative imaging confirms gross total resection. The patient gave informed consent for surgery and video recording. The institutional review board approval was deemed unnecessary. Used with permission from the Barrow Neurological Institute.

Demonstration of Microsurgical Technique and Nuances for the Resection of a Midbrain Tectal Glioma Via the Transcollicular Approach: 3-Dimensional Operative Video

2020 ◽  
Author(s):  
Sima Sayyahmelli ◽  
Jian Ruan ◽  
Emel Avci ◽  
Mustafa K Başkaya
Keyword(s):  
Signal Intensity ◽  
Cystic Mass ◽  
World Health ◽  
High Signal ◽  
Third Ventriculostomy ◽  
Ataxic Gait ◽  
3 Dimensional ◽  
Postoperative Mri ◽  
Magnetic Resonance Imaging Mri ◽  
Health Organization

Abstract Tectal gliomas are a rare subset of intrinsic brainstem lesions. The microsurgical resection of these lesions remains a major challenge.1,2 Transcollicular approaches on one side, via the superior or inferior colliculi or both, are neurologically well tolerated without obvious or major auditory or oculomotor consequences. However, any postoperative acute visually triggered saccadic abnormalities caused by iatrogenic superior colliculus damage generally resolve during the postoperative period, as other oculomotor structures compensate for these functions in unilateral lesions.  In this surgical video, we present a 37-yr-old man with long-standing seizures, new onset headaches, progressive ataxic gait, and imbalance. Magnetic resonance imaging (MRI) showed a circumscribed nonenhancing dorsal midbrain cystic mass with compression on the aqueduct causing hydrocephalus. The lesion had a low signal intensity on T1-weighted images and a high signal intensity on T2-weighted images. The patient first underwent an endoscopic third ventriculostomy. Although his headaches greatly improved after the third ventriculostomy, he remained quite symptomatic in terms of gait imbalance and ataxia. The patient underwent a supracerebellar, infratentorial, transcollicular approach for resection of the tectal tumor. Simultaneously, motor and somatosensory evoked potentials were monitored.  Both the surgery and the postoperative course were uneventful, with postoperative MRI showing gross total resection of the mass, and histopathology indicating a WHO (World Health Organization) grade I pilocytic astrocytoma. The patient continued to do well without recurrence at 2-yr follow-up.  In this video, we demonstrate step-by-step microsurgical techniques for resecting these challenging tectal gliomas via the infratentorial-supracerebellar-transcollicular approach. The patient consented to the procedure and publication of his images.

scholarly journals A giant frontal cavernous malformation with review of literature

2016 ◽  
Vol 07 (02) ◽  
pp. 279-282
Author(s):  
Arvind Sharma ◽  
Radhey Shyam Mittal
Keyword(s):  
Endothelial Cells ◽  
Smooth Muscle ◽  
World Literature ◽  
Rare Case ◽  
Indian Population ◽  
Cavernous Malformation ◽  
Neural Tissue ◽  
Mass Effect ◽  
Review Of Literature ◽  
Cavernous Malformations

ABSTRACTCavernous malformations (CMs) are vascular anomalies with dilated spaces called caverns. These spaces are lined by endothelial cells and collage and devoid of smooth muscle or intervening neural tissue, and filled with blood at various stages of stasis, thrombosis, organization, and calcification. Most CMs are relatively small in size but when they are large enough they can produce sing of mass effect and may simulate neoplastic, vascular, inflammatory pathology. Giant CM (size >6 cm) are very rare lesions and very few cases are reported in world literature. We are reporting such a rare case of a 16 year male. Our case is also unique in the sense that it is the largest reported CM in Indian population.

Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report

2021 ◽  
Author(s):  
Biren Khimji Patel ◽  
A Jaypalsinh Gohil ◽  
Prakash Nair ◽  
Easwer H.V. ◽  
Deepti A.N.
Keyword(s):  
Clinical Presentation ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Low Flow ◽  
Visual Field Defects ◽  
Optic Pathway ◽  
Endoscopic Endonasal ◽  
Cavernous Malformations ◽  
Magnetic Resonance Imaging Mri ◽  
Bitemporal Hemianopia

Abstract BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH). CLINICAL PRESENTATION A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM. CONCLUSION This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.

scholarly journals Transcallosal approach for third ventriculostomy and removal of midbrain cavernous malformation

2013 ◽  
Vol 34 (v1supplement) ◽  
pp. 1
Author(s):  
William T. Couldwell
Keyword(s):  
Brain Stem ◽  
Young Woman ◽  
Cavernous Malformation ◽  
Third Ventricle ◽  
Mass Effect ◽  
Third Ventriculostomy ◽  
Cavernous Malformations ◽  
Transcallosal Approach ◽  
The Third ◽  
Transforaminal Approach

Symptomatic brain stem cavernous malformations often present the dilemma of choosing an approach for their resection. Superior midline midbrain lesions are in a particularly challenging location, as they are less accessible via traditional lateral or posterior approaches. The author presents a case of a young woman who presented with a symptomatic cavernous malformation with surface presentation to the floor of the third ventricle. The lesion was causing sensory symptoms from local mass effect and hydrocephalus from occlusion of the Aqueduct of Sylvius. An approach was chosen to both perform a third ventriculostomy and remove the cavernous malformation. Through a right frontal craniotomy, a transcallosal–transforaminal approach was used to perform a third ventriculostomy. Through the same callosal opening, a subchoroidal approach was performed to provide access the cavernous malformation. The details of the procedure and nuances of technique are described in the narration.The video can be found here: http://youtu.be/zKKnehp7l2c.

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