CC BY-NC-ND 4.0 · J Neurol Surg B 2018; 79(S 05): S418-S419
DOI: 10.1055/s-0038-1669979
Skull Base: Operative Videos
Georg Thieme Verlag KG Stuttgart · New York

Extended Retrosigmoid Approach for the Resection of a Pontomedullary Junction Cavernous Malformation

Jaafar Basma
1  Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, United States
,
Vincent Nguyen
1  Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, United States
,
Jeffrey Sorenson
1  Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, United States
,
L. Madison Michael II
1  Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, United States
› Author Affiliations
Further Information

Address for correspondence

L. Madison Michael II, MD
Department of Neurosurgery, University of Tennessee
847 Monroe Avenue, Suite 427, Memphis, TN 38163
United States   

Publication History

31 May 2018

11 August 2018

Publication Date:
25 September 2018 (eFirst)

 

    Abstract

    Objectives To describe an extended retrosigmoid approach for the resection of a cavernoma involving the ponto-medullary junction, with emphasis on the microsurgical anatomy and technique.

    Design A retrosigmoid craniotomy is performed in the lateral decubitus position and the sigmoid sinus exposed. After opening the dura, sutures are placed medial to the sinus to allow its gentle mobilization. Cerebrospinal fluid (CSF) is drained from the cisterna magna, and cerebellopontine cistern, and dynamic retraction is used over the cerebellum. Subarachnoid dissection of the cerebellopontine angle gives access to cranial nerves IX/X, VII/VIII, and VI. Inspection of the pontomedullary junction medial to the facial nerve reveals hemosiderin staining in that region. A small pial opening is made, exposing the hemorrhagic cavity. The cavernous malformation is then identified, dissected circumferentially, and resected. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy.

    Participants The senior author performed the surgery. The video was edited by Drs. J.B. and V.N.

    Outcome Measures Outcome was assessed with extent of resection and postoperative neurological function.

    Results A gross total resection of the lesion was achieved. The patient did not develop any postoperative deficits.

    Conclusion Understanding the microsurgical anatomy of the cerebellopontine angle and meticulous microneurosurgical technique are necessary to achieve a complete resection of a brainstem cavernoma. The extended retrosigmoid approach provides an adequate corridor to the pontomedullary junction.

    The link to the video can be found at: https://youtu.be/FIKixWJT75w.


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    Zoom Image
    Fig. 1 The cavernous malformation is visualized at the surface of the pontomedullary junction with hemosiderin staining. Access to the lesion requires delicate exposure of the lower cranial nerves as detailed in this figure.
    Zoom Image
    Fig. 2 The cavernous malformation is seen clearly at the pontomedullary junction on this coronal magnetic resonance imaging (MRI). Postoperative contrasted imaging shows gross total resection of the lesion.

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    Quality:

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    Conflict of Interest

    None.

    Address for correspondence

    L. Madison Michael II, MD
    Department of Neurosurgery, University of Tennessee
    847 Monroe Avenue, Suite 427, Memphis, TN 38163
    United States   

      
    Zoom Image
    Fig. 1 The cavernous malformation is visualized at the surface of the pontomedullary junction with hemosiderin staining. Access to the lesion requires delicate exposure of the lower cranial nerves as detailed in this figure.
    Zoom Image
    Fig. 2 The cavernous malformation is seen clearly at the pontomedullary junction on this coronal magnetic resonance imaging (MRI). Postoperative contrasted imaging shows gross total resection of the lesion.