Endoscopic endonasal transclival resection of a ventral pontine cavernous malformation: technical case report

Brainstem cavernous malformations are challenging due to the critical anatomy and potential surgical risks. Anterolateral, lateral, and dorsal surgical approaches provide limited ventral exposure of the brainstem. The authors present a case of a midline ventral pontine cavernous malformation resected through an endoscopic endonasal transclival approach based on minimal brainstem transection, negligible cranial nerve manipulation, and a straightforward trajectory. Technical and reconstruction technique advances in endoscopic endonasal skull base surgery provide a direct, safe, and effective corridor to the brainstem.

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The Role of 3D tractography in Skull Base Surgery: Technological Advances, Feasibility, and Early Clinical Assessment with Anterior Skull Base Meningiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713775 ◽

2020 ◽

Author(s):

Srikant S. Chakravarthi ◽

Melanie B. Fukui ◽

Alejandro Monroy-Sosa ◽

Lior Gonen ◽

Austin Epping ◽

...

Keyword(s):

Skull Base ◽

Cranial Nerve ◽

Skull Base Surgery ◽

Three Dimensional ◽

Qualitative Assessment ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Volume Functional ◽

Signal Abnormality ◽

Anterior Cranial Base

Abstract Objective The aim of this study is to determine feasibility of incorporating three-dimensional (3D) tractography into routine skull base surgery planning and analyze our early clinical experience in a subset of anterior cranial base meningiomas (ACM). Methods Ninety-nine skull base endonasal and transcranial procedures were planned in 94 patients and retrospectively reviewed with a further analysis of the ACM subset. Main Outcome Measures (1) Automated generation of 3D tractography; (2) co-registration 3D tractography with computed tomography (CT), CT angiography (CTA), and magnetic resonance imaging (MRI); and (3) demonstration of real-time manipulation of 3D tractography intraoperatively. ACM subset: (1) pre- and postoperative cranial nerve function, (2) qualitative assessment of white matter tract preservation, and (3) frontal lobe fluid-attenuated inversion recovery (FLAIR) signal abnormality. Results Automated 3D tractography, with MRI, CT, and CTA overlay, was produced in all cases and was available intraoperatively. ACM subset: 8 (44%) procedures were performed via a ventral endoscopic endonasal approach (EEA) corridor and 12 (56%) via a dorsal anteromedial (DAM) transcranial corridor. Four cases (olfactory groove meningiomas) were managed with a combined, staged approach using ventral EEA and dorsal transcranial corridors. Average tumor volume reduction was 90.3 ± 15.0. Average FLAIR signal change was –30.9% ± 58.6. 11/12 (92%) patients (DAM subgroup) demonstrated preservation of, or improvement in, inferior fronto-occipital fasciculus volume. Functional cranial nerve recovery was 89% (all cases). Conclusions It is feasible to incorporate 3D tractography into the skull base surgical armamentarium. The utility of this tool in improving outcomes will require further study.

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Endoscopic Endonasal Transclival Approach to Ventral Pontine Cavernous Malformation: Case Report

Frontiers in Surgery ◽

10.3389/fsurg.2021.654837 ◽

2021 ◽

Vol 8 ◽

Author(s):

Xiao Dong ◽

Xiaoyu Wang ◽

Anwen Shao ◽

Jianmin Zhang ◽

Yuan Hong

Keyword(s):

Case Report ◽

High Risk ◽

Cavernous Malformation ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Dorsal Approach ◽

Endoscopic Endonasal ◽

Cavernous Malformations ◽

Individualized Approach

Ventral medial pontine cavernous malformations are challenging due to the location in eloquent tissue, surrounding critical anatomy, and potential symptomatic bleeding. Conventional approaches, such as anterolateral, lateral and dorsal approach, are associated with high risk of deleterious consequences due to excessive traction and damage to the surrounding tissues. The authors present an endoscopic endonasal approach for the resection of midline ventral pontine cavernous malformations, which follows principles of optimal access to brainstem cavernous malformations as the “two-point method.” No CSF leak or any other complications are obtained. The successful outcomes indicate that an individualized approach should be chosen before the surgery for brainstem cavernous malformations. With the advance of techniques, endoscopic endonasal approach could provide the most direct route to ventral pontine lesions with safety and efficiency.

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