Using the Lateral Pontine Safe Entry Zone for Resection of Deep-Seated Cavernous Malformations in the Lateral Pons: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (5) ◽  
pp. E518-E519
Author(s):  
Daniel D Cavalcanti ◽  
Joshua S Catapano ◽  
Paulo Niemeyer Filho
Keyword(s):  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Cranial Nerves ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
History Of ◽  
Tumor Biopsies ◽  
Safe Entry Zone

Abstract The retrosigmoid approach is one of the main approaches used in the surgical management of pontine cavernous malformations. It definitely provides a lateral route to large central lesions but also makes possible resection of some ventral lesions as an alternative to the petrosal approaches. However, when these vascular malformations do not emerge on surface, one of the safe corridors delimited by the origin of the trigeminal nerve and the seventh-eight cranial nerve complex can be used.1-5  Baghai et al2 described the lateral pontine safe entry zone in 1982, as an alternative to approaches through the floor of the fourth ventricle when performing tumor biopsies. They advocated a small neurotomy performed right between the emergence of the trigeminal nerve and the facial-vestibulocochlear cranial nerves complex. Accurate image guidance, intraoperative cranial nerve monitoring, and comprehensive anatomical knowledge are critical for this approach.4,5  Knowing the natural history of a brainstem cavernous malformation after bleeding,6 we sought to demonstrate in this video: (1) the use of the retrosigmoid craniotomy in lateral decubitus for resection of deep-seated pontine cavernous malformations; (2) the wide opening of arachnoid membranes and dissection of the superior petrosal vein complex to improve surgical freedom and prevent use of fixed cerebellar retraction; and (3) the opening of the petrosal fissure and exposure of the lateral pontine zone for gross total resection of a cavernous malformation in a 19-yr-old female with a classical crossed brainstem syndrome. She had full neurological recovery after 3 mo of follow-up.  The patient consented in full to the surgical procedure and publication of the video and manuscript.

scholarly journals Large cavernous malformations in infant

2021 ◽  
Vol 32 (2) ◽  
pp. 149-155
Author(s):  
João Pedro Einsfeld Britz ◽  
Ildo Sonda ◽  
Renato Luis Calloni ◽  
Yan Bicca ◽  
Arthur Aguzzoli
Keyword(s):  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Pediatric Population ◽  
Previous History ◽  
Resonance Imaging ◽  
Cavernous Malformations ◽  
History Of ◽  
The Central Nervous System ◽  
Radiological Aspect ◽  
Clonic Seizures

Cavernous malformations are rare vascular malformations in the central nervous system. We present the case of a 2-month-old female patient who presented tonic-clonic seizures, with no previous history of seizures. Magnetic resonance imaging showed a 5.6 cm tumor in the left parieto-occipital region. The radiological aspect of the tumor initially suggested an anaplastic meningioma. After surgical treatment and anatomopathological analysis, it was found to be a cavernous malformation. Cavernous malformations, or cavernomas, are rare lesions and even more rare is the occurrence of large cavernomas. In the pediatric population, although still quite rare, they usually are presented as larger cavernomas. Surgical resection is considered the most effective treatment.

scholarly journals Posterolateral route for a midbrain cavernous malformation reaching the anterior surface of the brainstem

2019 ◽  
Vol 1 (1) ◽  
pp. V13
Author(s):  
Michel W. Bojanowski ◽  
Gunness V. R. Nitish ◽  
Gilles El Hage ◽  
Kim Lalonde ◽  
Chiraz Chaalala ◽  
...  
Keyword(s):  
Brain Tissue ◽  
Cavernous Malformation ◽  
Normal Brain ◽  
Anterior Surface ◽  
Normal Brain Tissue ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Supracerebellar Infratentorial Approach ◽  
Pass Through ◽  
Safe Entry Zone

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/7kt-OQuBmz0.

Posterior petrosectomy for resection of pontine cavernous malformation

2019 ◽  
Vol 1 (2) ◽  
pp. V18
Author(s):  
Avital Perry ◽  
Thomas J. Sorenson ◽  
Christopher S. Graffeo ◽  
Colin L. Driscoll ◽  
Michael J. Link
Keyword(s):  
Real Time ◽  
Surgical Resection ◽  
Cavernous Malformation ◽  
Low Pressure ◽  
Vascular Lesions ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Microsurgical Techniques ◽  
Safe Entry Zone ◽  
Ultrasound Probes

Cavernous malformations (CMs) are low-pressure, focal, vascular lesions that may occur within the brainstem and require treatment, which can be a substantial challenge. Herein, we demonstrate the surgical resection of a hemorrhaged brainstem CM through a posterior petrosectomy approach. After dissection of the overlying vascular and meningeal structures, a safe entry zone into the brainstem is identified based on local anatomy and intraoperative neuronavigation. Small ultrasound probes can also be useful for obtaining real-time intraoperative feedback. The CM is internally debulked and resected in a piecemeal fashion through an opening smaller than the CM itself. As brainstem CMs are challenging lesions, knowledge of several surgical nuances and adoption of careful microsurgical techniques are requisite for success.The video can be found here: https://youtu.be/szB6YpzkuCo.

scholarly journals Median suboccipital craniotomy and telovelar approach for posterior pontine cavernous malformations

2019 ◽  
Vol 1 (1) ◽  
pp. V8
Author(s):  
Daniel D. Cavalcanti ◽  
Paulo Niemeyer Filho
Keyword(s):  
Cavernous Malformation ◽  
Resonance Imaging ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Suboccipital Craniotomy ◽  
Telovelar Approach ◽  
Lateral Decubitus ◽  
Neurologically Intact ◽  
Safe Entry Zone

The pons is the preferred location for cavernous malformations in the brainstem. When these lesions do not surface, it is critical to select the optimal safe entry zone to reduce morbidity.1–3 In this video, we demonstrate in a stepwise manner the medial suboccipital craniotomy and the telovelar approach performed in a lateral decubitus position. They were used to successfully resect a pontine cavernous malformation in a centroposterior location in a 19-year-old patient with diplopia, right-sided numbness, and imbalance. The paramedian supracollicular safe entry zone was used once the lesion did not reach the ependymal surface.2,3 Late magnetic resonance imaging demonstrated total resection and the patient was neurologically intact after 3 months of follow-up. The approach is also demonstrated in a cadaveric dissection to better illustrate all steps.The video can be found here: https://youtu.be/ChArkxA8kig.

Cavernous Malformation of the Trigeminal Nerve Manifesting with Trigeminal Neuralgia: Case Report

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. E623-E623 ◽  
Author(s):  
Vivek R. Deshmukh ◽  
Jonathan S. Hott ◽  
Peyman Tabrizi ◽  
Peter Nakaji ◽  
Iman Feiz-Erfan ◽  
...  
Keyword(s):  
Trigeminal Neuralgia ◽  
Trigeminal Nerve ◽  
Nerve Root ◽  
Facial Pain ◽  
Clinical Presentation ◽  
Cavernous Malformation ◽  
Resonance Imaging ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Root Entry Zone

Abstract OBJECTIVE AND IMPORTANCE: We describe a patient with a cavernous malformation within the trigeminal nerve at the nerve root entry zone who presented with trigeminal neuralgia. CLINICAL PRESENTATION: A 52-year-old woman sought treatment after experiencing dizziness and lancinating left facial pain for almost a year. Neurological examination revealed diminished sensation in the distribution of the trigeminal nerve on the left. Magnetic resonance imaging demonstrated a minimally enhancing lesion affecting the trigeminal nerve. INTERVENTION: The patient underwent a retrosigmoid craniotomy. At the nerve root entry zone, the trigeminal nerve was edematous with hemosiderin staining. The lesion, which was resected with microsurgical technique, had the appearance of a cavernous malformation on gross and histological examination. The patient's pain improved significantly after resection. CONCLUSION: Cavernous malformations can afflict the trigeminal nerve and cause trigeminal neuralgia. Microsurgical excision can be performed safely and is associated with improvement in symptoms.

scholarly journals Fully endoscopic access and resection of hemorrhaged cavernous malformation of the posterior midbrain

2019 ◽  
Vol 1 (1) ◽  
pp. V14
Author(s):  
Giulio Cecchini ◽  
Giovanni Vitale ◽  
Thomas J. Sorenson ◽  
Francesco Di Biase
Keyword(s):  
Brain Tissue ◽  
Cavernous Malformation ◽  
Normal Brain ◽  
Anterior Surface ◽  
Normal Brain Tissue ◽  
Cavernous Malformations ◽  
Entry Zone ◽  
Supracerebellar Infratentorial Approach ◽  
Pass Through ◽  
Safe Entry Zone

Cavernous malformations in the midbrain can be accessed via several safe entry zones. The accepted rule of thumb is to enter at the point where the lesion is visible at the surface of the brainstem to pass through as little normal brain tissue as possible. However, in some cases, in order to avoid critical neural structures, this rule may not apply. A different safe entry zone can be chosen. Our video presents a case of a ruptured cavernous malformation in the midbrain reaching its anterior surface which was successfully resected via a posterolateral route using the supracerebellar infratentorial approach.The video can be found here: https://youtu.be/j7VTqRO7qd4.

scholarly journals Extreme Lateral Supracerebellar Infratentorial Approach to the Lateral Midbrain

2018 ◽  
Vol 79 (S 05) ◽  
pp. S415-S417
Author(s):  
M. Kalani ◽  
William Couldwell
Keyword(s):  
Cranial Nerves ◽  
Sudden Onset ◽  
Superior Cerebellar Artery ◽  
Entry Zone ◽  
Cerebellar Artery ◽  
Sensory Disturbances ◽  
History Of ◽  
Supracerebellar Infratentorial Approach ◽  
The Right ◽  
Piecemeal Resection

This video illustrates the case of a 52-year-old man with a history of multiple bleeds from a lateral midbrain cerebral cavernous malformation, who presented with sudden-onset headache, gait instability, and left-sided motor and sensory disturbances. This lesion was eccentric to the right side and was located in the dorsolateral brainstem. Therefore, the lesion was approached via a right-sided extreme lateral supracerebellar infratentorial (exSCIT) craniotomy with monitoring of the cranial nerves. This video demonstrates the utility of the exSCIT for resection of dorsolateral brainstem lesions and how this approach gives the surgeon ready access to the supracerebellar space, and cerebellopontine angle cistern. The lateral mesencephalic safe entry zone can be accessed from this approach; it is identified by the intersection of branches of the superior cerebellar artery and the fourth cranial nerve with the vein of the lateral mesencephalic sulcus. The technique of piecemeal resection of the lesion from the brainstem is presented. Careful patient selection and respect for normal anatomy are of paramount importance in obtaining excellent outcomes in operations within or adjacent to the brainstem.The link to the video can be found at: https://youtu.be/aIw-O2Ryleg.

Targeting the cranial nerve: microradiosurgery for trigeminal neuralgia with CISS and 3D-Flash MR imaging sequences

2005 ◽  
Vol 102 ◽  
pp. 107-110 ◽  
Author(s):  
Vasilios A. Zerris ◽  
Georg C. Noren ◽  
William A. Shucart ◽  
Jeff Rogg ◽  
Gerhard M. Friehs
Keyword(s):  
Mr Imaging ◽  
Trigeminal Neuralgia ◽  
Gamma Knife ◽  
Trigeminal Nerve ◽  
Cranial Nerve ◽  
Fusion Imaging ◽  
Vascular Compression ◽  
Content Type ◽  
History Of ◽  
Fine Print

Object.The authors undertook a study to identify magnetic resonance (MR) imaging techniques that can be used reliably during gamma knife surgery (GKS) to identify the trigeminal nerve, surrounding vasculature, and areas of compression.Methods.Preoperative visualization of the trigeminal nerve and surrounding vasculature as well as targeting the area of vascular compression may increase the effectiveness of GKS for trigeminal neuralgia. During the past years our gamma knife centers have researched different MR imaging sequences with regard to their ability to visualize cranial nerves and vascular structures. Constructive interference in steady-state (CISS) fusion imaging with three-dimensional gradient echo sequences (3D-Flash) was found to be of greatest value in the authors' 25 most recent patients.In 24 (96%) out of the 25 patients, the fifth cranial nerve, surrounding vessels, and areas of compression could be reliably identified using CISS/3D-Flash. The MR images were acceptable despite patients' history of microvascular decompression, radiofrequency (RF) ablation, or concomitant disease. In one of 25 patients with a history of multiple RF lesions, the visualization was inadequate due to severe trigeminal nerve atrophy.Conclusions.The CISS/3D-Flash fusion imaging has become the preferred imaging method at the authors' institutions during GKS for trigeminal neuralgia. It affords the best visualization of the trigeminal nerve, surrounding vasculature, and the precise location of vascular compression.

Unique enlarging cavernous malformation secondary to abnormal arteriovenous shunting through an associated developmental venous anomaly

2021 ◽  
pp. 197140092110428
Author(s):  
Nimisha Parikh ◽  
Richard Williamson ◽  
Matthew Kulzer ◽  
Albert Sohn ◽  
Warren M Chang ◽  
...  
Keyword(s):  
Unusual Case ◽  
Cavernous Malformation ◽  
Vascular Malformations ◽  
Venous Hypertension ◽  
Developmental Venous Anomaly ◽  
Venous Anomaly ◽  
Arteriovenous Shunting ◽  
Cavernous Malformations ◽  
Progressive Growth

Cavernous malformations are angiographically occult vascular malformations. They are often associated with a developmental venous anomaly through poorly understood mechanisms. We present an unusual case of a gradually enlarging cavernous malformation associated with a developmental venous anomaly with arteriovenous shunting, suggesting venous hypertension or reflux as a potential cause of progressive growth.

Left retrosigmoid craniotomy for cavernous malformation of the middle cerebellar peduncle

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Jonathan Russin ◽  
David J. Fusco ◽  
Robert F. Spetzler
Keyword(s):  
Cerebrospinal Fluid ◽  
Cavernous Malformation ◽  
Lateral Wall ◽  
Petrous Bone ◽  
Sigmoid Sinus ◽  
Middle Cerebellar Peduncle ◽  
Cavernous Malformations ◽  
Lateral Border ◽  
History Of ◽  
Cerebellar Peduncle

We present a 25-year-old female with a history of multiple intracranial cavernous malformations complaining of vertigo. Imaging is significant for increasing size of a lesion in her left cerebellar peduncle. Given the proximity to the lateral border of the cerebellar peduncle, a retrosigmoid approach was chosen. After performing a craniotomy that exposed the transverse-sigmoid sinus junction, the dura was open and reflected. The arachnoid was sharply opened and cerebrospinal fluid was aspirated to allow the cerebellum to fall away from the petrous bone. The cerebellopontine fissure was then opened to visualize the lateral wall of the cerebellar peduncle. The cavernous malformation was entered and resected.The video can be found here: http://youtu.be/P7mpVbaCiJE.

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