Contralateral Supracerebellar Infratentorial Approach for Resection of Thalamic Cavernous Malformations

Background Surgical resection of thalamic cavernous malformations (CM) is technically challenging due to the presence of eloquent cortex and critical neurovascular structures in their vicinity. The supracerebellar infratentorial (SCIT) approach has been utilized to approach CMs in the posterior thalamus. The median, paramedian, and extreme lateral variants of the SCIT approach have been previously described.

Objective Our study aims to describe a fourth variant, the contralateral SCIT (cSCIT) approach, to target CMs within the posterior thalamus.

Methods This is a retrospective review of patients with thalamic CMs treated surgically from 1997 to present. During this time period, 75 patients underwent the SCIT approach, of which 3 underwent the cSCIT approach. Surgeries were performed in the sitting position with gravity retraction of the cerebellum. The historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient.

Results All three patients presented with at least one (sometimes multiple) hemorrhage(s) with resulting neurological deficits. All lesions were in the right posterior thalamus and were approached via a left cSCIT. All lesions were completely resected without intraoperative complication. Intraoperatively, the contralateral view allowed for better inspection of the lateral CM border. There were no new or worsening permanent neurological deficits. No evidence of rebleeding or recurrence has been observed.

Conclusion This study establishes the surgical feasibility of a cSCIT approach in resection of symptomatic posterior thalamic CMs. It demonstrates the potential application for this procedure in extending the surgical trajectory superiorly and laterally without having to transgress normal brain parenchyma.

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