BACKGROUND AND IMPORTANCE: Cavernous malformations of the brainstem are a dilemma in terms of deciding when to operate, and they remain difficult to access surgically. We present a novel approach for the resection of a brainstem cavernous malformation. CLINICAL PRESENTATION: A 59-year-old woman presented with a 1-month history of intermittent dysarthria, right facial weakness, and left arm and leg weakness. A magnetic resonance image revealed a 2-cm mass in the pons with blood products of differing ages, consistent with a cavernous malformation. We discussed with her the risks of surgical resection and conservative management. She decided to pursue conservative management. Two weeks later, she returned to the emergency room with diplopia and left-sided hemiplegia. Acute hemorrhage within the right pons was seen. She then chose to undergo surgical resection. CONCLUSION: The patient underwent an endoscopic transnasal approach for resection of a pontine cavernous malformation. Image guidance was used to identify key anatomic landmarks. A gross total resection was achieved without new neurological deficits. With physical and occupational therapy, the patient developed antigravity strength in her left upper and lower extremities before discharge. At her 4-week follow-up, she was ambulating independently with the assistance of a cane. We report the successful gross total resection of a pontine cavernous malformation via an endoscopic transnasal approach. This patient had improvement in neurological symptoms after surgical resection with minimal surgical morbidity. Technologic advances in endoscopic skull base approaches have provided access to lesions of the skull base previously requiring more invasive approaches.
BACKGROUND AND IMPORTANCE: Cavernous malformations of the brainstem are a dilemma in terms of deciding when to operate, and they remain difficult to access surgically. We present a novel approach for the resection of a brainstem cavernous malformation. CLINICAL PRESENTATION: A 59-year-old woman presented with a 1-month history of intermittent dysarthria, right facial weakness, and left arm and leg weakness. A magnetic resonance image revealed a 2-cm mass in the pons with blood products of differing ages, consistent with a cavernous malformation. We discussed with her the risks of surgical resection and conservative management. She decided to pursue conservative management. Two weeks later, she returned to the emergency room with diplopia and left-sided hemiplegia. Acute hemorrhage within the right pons was seen. She then chose to undergo surgical resection. CONCLUSION: The patient underwent an endoscopic transnasal approach for resection of a pontine cavernous malformation. Image guidance was used to identify key anatomic landmarks. A gross total resection was achieved without new neurological deficits. With physical and occupational therapy, the patient developed antigravity strength in her left upper and lower extremities before discharge. At her 4-week follow-up, she was ambulating independently with the assistance of a cane. We report the successful gross total resection of a pontine cavernous malformation via an endoscopic transnasal approach. This patient had improvement in neurological symptoms after surgical resection with minimal surgical morbidity. Technologic advances in endoscopic skull base approaches have provided access to lesions of the skull base previously requiring more invasive approaches.
Authors: Francesco Belotti; Francesco Tengattini; Davide Mattavelli; Marco Ferrari; Antonio Fiorentino; Silvia Agnelli; Alberto Schreiber; Piero Nicolai; Marco Maria Fontanella; Francesco Doglietto Journal: Neurosurg Rev Date: 2020-02-14 Impact factor: 3.042