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Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus

Endoscopic view of surgical field. View of basilar artery and hemorrhagic staining of pons (arrow) (a). Expulsion of blood products following pial opening (b). Surgical cavity following resection of cavernous malformation (c)
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Figure 2: Endoscopic view of surgical field. View of basilar artery and hemorrhagic staining of pons (arrow) (a). Expulsion of blood products following pial opening (b). Surgical cavity following resection of cavernous malformation (c)

Mentions: A 2 surgeon, four-handed technique was used to perform the approach and resection. The sellar floor and basion marked the superior/inferior limits of the bony exposure, and the petrous portion of the internal carotid arteries bilaterally marked the limits of the lateral bony exposure. A midline durotomy was created and extended to the right where there was minimal discoloration of the brainstem. Stereotaxy was used to confirm the location of the lesion. A corticectomy was made and blood products expelled from the cavity [Figure 2]. The CM was resected in a piecemeal fashion, and a developmental venous anomaly (DVA) was identified and preserved. Autologous fascia lata from the patient's right thigh and nasoseptal flaps were used to reconstruct the defect. Postoperative imaging demonstrated complete resection of the cavernoma, preservation of the associated DVA, and wide resection of the clivus limited by the carotid arteries [Figure 3].


Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature.

Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JY - Surg Neurol Int (2015)

Endoscopic view of surgical field. View of basilar artery and hemorrhagic staining of pons (arrow) (a). Expulsion of blood products following pial opening (b). Surgical cavity following resection of cavernous malformation (c)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4418103&req=5

Figure 2: Endoscopic view of surgical field. View of basilar artery and hemorrhagic staining of pons (arrow) (a). Expulsion of blood products following pial opening (b). Surgical cavity following resection of cavernous malformation (c)
Mentions: A 2 surgeon, four-handed technique was used to perform the approach and resection. The sellar floor and basion marked the superior/inferior limits of the bony exposure, and the petrous portion of the internal carotid arteries bilaterally marked the limits of the lateral bony exposure. A midline durotomy was created and extended to the right where there was minimal discoloration of the brainstem. Stereotaxy was used to confirm the location of the lesion. A corticectomy was made and blood products expelled from the cavity [Figure 2]. The CM was resected in a piecemeal fashion, and a developmental venous anomaly (DVA) was identified and preserved. Autologous fascia lata from the patient's right thigh and nasoseptal flaps were used to reconstruct the defect. Postoperative imaging demonstrated complete resection of the cavernoma, preservation of the associated DVA, and wide resection of the clivus limited by the carotid arteries [Figure 3].

Bottom Line: Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII.The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not.It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104.

ABSTRACT

Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

No MeSH data available.


Related in: MedlinePlus