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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

Preoperative axial T2-weighted MRI demonstrating a cavernous malformation of the left posterolateral pons adjacent to the cranial nerve VII/VIII complex
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Figure 7: Preoperative axial T2-weighted MRI demonstrating a cavernous malformation of the left posterolateral pons adjacent to the cranial nerve VII/VIII complex

Mentions: The patient is a 59-year-old female who developed hearing loss in the left ear approximately 4 weeks prior to presentation. Three weeks after the onset of symptoms, she also developed left facial paresis and was referred to a neurologist. MRI demonstrated a heterogeneous lesion measuring 1.8 × 1.4 cm in the largest cross section with mixed-age blood products and hemosiderin ring consistent with a CM of the left pons, adjacent to the root entry zones of the 7th and 8th cranial nerves [Figures 7 and 8].


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)

Preoperative axial T2-weighted MRI demonstrating a cavernous malformation of the left posterolateral pons adjacent to the cranial nerve VII/VIII complex
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 7: Preoperative axial T2-weighted MRI demonstrating a cavernous malformation of the left posterolateral pons adjacent to the cranial nerve VII/VIII complex
Mentions: The patient is a 59-year-old female who developed hearing loss in the left ear approximately 4 weeks prior to presentation. Three weeks after the onset of symptoms, she also developed left facial paresis and was referred to a neurologist. MRI demonstrated a heterogeneous lesion measuring 1.8 × 1.4 cm in the largest cross section with mixed-age blood products and hemosiderin ring consistent with a CM of the left pons, adjacent to the root entry zones of the 7th and 8th cranial nerves [Figures 7 and 8].

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