Surgical treatment of brainstem cavernous malformation with concomitant developmental venous anomaly

Abstract

Surgical resection of brainstem cavernous malformations (BCMs) is a high-risk procedure and can be challenging to the neurosurgeon. Lateral surgical routes are becoming increasingly used to approach ventrolaterally brainstem cavernoma. Surgical approach decision depends on the location of the cavernoma in the brainstem and a possible association with brainstem developmental venous anomalies (DVAs). DVA can affect the formation and clinical course of cavernous malformation (CM). CMs related to DVAs tend to have more aggressive behavior than isolated CM. In cases of DVAs associated with hemorrhage, CMs are most often the site of bleeding rather than DVAs themselves. In this case report, we present a 24-year-old woman with a pontomedullary CM and associated dorsally located DVA. BCM was operated through a far lateral suboccipital craniotomy. Brainstem entry point was at inferior olive with extension to the pontomedullary sulcus. This approach should be preferred as a safe surgical exposure to the central and paramedian pontomedullary cavernoma, especially in the cases with associated intraparenchymal brainstem DVA. Such surgical exposure allows preservation of the concomitant brainstem DVA.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case

“…Besides, six patients whose DVA had been left intact did not present recurrence of CCM. More recent reports continue to support the elective microsurgical excision of symptomatic CCM without touching the associated DVA [91]. Venous sacrifice in cranial neurosurgical procedures has always been considered hazardous for fear of the potential disastrous consequences of venous infarction [92,93], which are very difficult to predict [94].…”