A 34-Year-Old Woman with Brainstem Cavernous Malformation: The Anterior Transcallosal Transchoroidal Approach and Literature Review

Abstract

Mesencephalic cavernous malformations (MeCMs) account for 4 to 35% of the cavernous malformations of the central nervous system and are generally rare. Surgical resection of brainstem cavernomas are high-risk procedures and can be challenging to the neurosurgeon. Several approaches have been described, but the approach must allow for a straight line of sight in which the surgeon, the pial incision, and the MeCM are all collinear. This alignment provides the best view of the lesion while minimizing the need for brainstem retraction. The pial incision should be chosen to minimize the distance to the lesion while avoiding critical nuclei and tracts. In this case report, we present a 34-year-old woman with a MeCM resected by an anterior transcallosal transchoroidal approach with minimal damage to surrounding brain tissue. Although rarely used, it should be considered a valuable alternative to ventrally located brainstem cavernomas.

Keywords

cavernous malformation - brainstem cavernoma - surgical approach - transcallosal transchoroidal approach - surgical complications - brainstem hemorrhage

• References

• 1 Bertalanffy H, Benes L, Miyazawa T, Alberti O, Siegel AM, Sure U. Cerebral cavernomas in the adult. Review of the literature and analysis of 72 surgically treated patients. Neurosurg Rev 2002; 25 (1-2) 1-53 ; discussion 54–55
• 2 Dukatz T, Sarnthein J, Sitter H , et al. Quality of life after brainstem cavernoma surgery in 71 patients. Neurosurgery 2011; 69 (3) 689-695
• 3 Gross BA, Batjer HH, Awad IA, Bendok BR. Brainstem cavernous malformations. Neurosurgery 2009; 64 (5) E805-E818 ; discussion E818
• 4 Gross BA, Batjer HH, Awad IA, Bendok BR, Du R. Brainstem cavernous malformations: 1390 surgical cases from the literature. World Neurosurg 2013; 80 (1–2) 89-93
• 5 Ohue S, Fukushima T, Kumon Y, Ohnishi T, Friedman AH. Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques. Neurosurg Rev 2010; 33 (3) 315-322 ; discussion 323–324
• 6 Giliberto G, Lanzino DJ, Diehn FE, Factor D, Flemming KD, Lanzino G. Brainstem cavernous malformations: anatomical, clinical, and surgical considerations. Neurosurg Focus 2010; 29 (3) E9
• 7 Abla AA, Lekovic GP, Turner JD, de Oliveira JG, Porter R, Spetzler RF. Advances in the treatment and outcome of brainstem cavernous malformation surgery: a single-center case series of 300 surgically treated patients. Neurosurgery 2011; 68 (2) 403-414 ; discussion 414–415
• 8 Horgan MA, Delashaw JB, Schwartz MS, Kellogg JX, Spektor S, McMenomey SO. Transcrusal approach to the petroclival region with hearing preservation. Technical note and illustrative cases. J Neurosurg 2001; 94 (4) 660-666
• 9 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 1991; 28 (6) 869-875 ; discussion 875–876
• 10 Miller CG, van Loveren HR, Keller JT, Pensak M, el-Kalliny M, Tew Jr JM. Transpetrosal approach: surgical anatomy and technique. Neurosurgery 1993; 33 (3) 461-469 ; discussion 469
• 11 Reisch R, Bettag M, Perneczky A. Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem. Surg Neurol 2001; 56 (2) 106-115 ; discussion 115–116
• 12 Spetzler RF, Sanai N. The quiet revolution: retractorless surgery for complex vascular and skull base lesions. J Neurosurg 2012; 116 (2) 291-300
• 13 Apuzzo ML, Chikovani OK, Gott PS , et al. Transcallosal, interfornicial approaches for lesions affecting the third ventricle: surgical considerations and consequences. Neurosurgery 1982; 10 (5) 547-554
• 14 Tomasello F, Cardali S, Angileri FF, Conti A. Transcallosal approach to third ventricle tumors: how I do it. Acta Neurochir (Wien) 2013; 155 (6) 1031-1034
• 15 Wen HT, Rhoton Jr AL, de Oliveira E. Transchoroidal approach to the third ventricle: an anatomic study of the choroidal fissure and its clinical application. Neurosurgery 1998; 42 (6) 1205-1217 ; discussion 1217–1219
• 16 Chang EF, Gabriel RA, Potts MB, Berger MS, Lawton MT. Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes. Clinical article. J Neurosurg 2011; 114 (3) 814-827
• 17 Kasowski HJ, Nahed BV, Piepmeier JM. Transcallosal transchoroidal approach to tumors of the third ventricle. Neurosurgery 2005; 57 (4, Suppl): 361-366 ; discussion 361–366
• 18 Ferroli P, Sinisi M, Franzini A, Giombini S, Solero CL, Broggi G. Brainstem cavernomas: long-term results of microsurgical resection in 52 patients. Neurosurgery 2005; 56 (6) 1203-1212 ; discussion 1212–1214
• 19 Ulm AJ, Russo A, Albanese E , et al. Limitations of the transcallosal transchoroidal approach to the third ventricle. J Neurosurg 2009; 111 (3) 600-609
• 20 Porter RW, Detwiler PW, Spetzler RF , et al. Cavernous malformations of the brainstem: experience with 100 patients. J Neurosurg 1999; 90 (1) 50-58
• 21 Steinberg GK, Chang SD, Gewirtz RJ, Lopez JR. Microsurgical resection of brainstem, thalamic, and basal ganglia angiographically occult vascular malformations. Neurosurgery 2000; 46 (2) 260-270 ; discussion 270–271
• 22 de Oliveira JG, Lekovic GP, Safavi-Abbasi S , et al. Supracerebellar infratentorial approach to cavernous malformations of the brainstem: surgical variants and clinical experience with 45 patients. Neurosurgery 2010; 66 (2) 389-399
• 23 Dammers R, Delwel EJ, Krisht AF. Cavernous hemangioma of the mesencephalon: tonsillouveal transaqueductal approach. Neurosurgery 2009; 64 (5) (Suppl. 02) 296-299 ; discussion 299–300
• 24 Garber ST, Couldwell WT. Resection of an inferior pontine cavernous malformation using a far-lateral transcondylar approach. Acta Neurochir (Wien) 2011; 153 (12) 2461-2464
• 25 Mussi AC, Rhoton Jr AL. Telovelar approach to the fourth ventricle: microsurgical anatomy. J Neurosurg 2000; 92 (5) 812-823
• 26 Chen L, Zhao Y, Zhou L, Zhu W, Pan Z, Mao Y. Surgical strategies in treating brainstem cavernous malformations. Neurosurgery 2011; 68 (3) 609-620 ; discussion 620–621
• 27 Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. Surg Neurol 2009; 72 (Suppl. 02) S3-S9 ; discussion S9–S10
• 28 Wang CC, Liu A, Zhang JT, Sun B, Zhao YL. Surgical management of brain-stem cavernous malformations: report of 137 cases. Surg Neurol 2003; 59 (6) 444-454 ; discussion 454
• 29 Hauck EF, Barnett SL, White JA, Samson D. Symptomatic brainstem cavernomas. Neurosurgery 2009; 64 (1) 61-70 ; discussion 70–71
• 30 Chen X, Weigel D, Ganslandt O, Buchfelder M, Nimsky C. Diffusion tensor imaging and white matter tractography in patients with brainstem lesions. Acta Neurochir (Wien) 2007; 149 (11) 1117-1131 ; discussion 1131
• 31 Kasowski H, Piepmeier JM. Transcallosal approach for tumors of the lateral and third ventricles. Neurosurg Focus 2001; 10 (6) E3