Insular cavernous malformation resection through a minipterional, transsylvian approach.

Peyton L Nisson,Peter Nakaji,Whitney S James,Xiaochun Zhao,Robert T Wicks,David Xu

doi:10.3171/2019.7.focusvid.19148

Abstract

Cavernous malformations of the brain are low-flow vascular lesions that have a propensity to hemorrhage. Extensive surgical approaches are often required for operative cure of deep-seated lesions. A 23-year-old female presented with a cavernous malformation of the left posterior insula with surrounding hematoma measuring up to 3 cm. A minimally invasive (mini-)pterional craniotomy with a transsylvian approach was selected. Endoscopic assistance was utilized to confirm complete resection of the lesion. The minipterional craniotomy is a minimally invasive approach that provides optimal exposure for sylvian fissure dissection and resection of many temporal and insular lesions.The video can be found here: https://youtu.be/9z6_EhU6lxs.

Highlights

This video illustrates a minimally invasive, endoscopic pterional craniotomy for transsylvian resection of a cavernous malformation
The MRI scans illustrate a relatively deep-seated cavernous malformation located in the low posterior insula
We see that there are a number of bridging veins in this area as well as the middle cerebral artery and branches

Summary

Introduction

This video illustrates a minimally invasive, endoscopic pterional craniotomy for transsylvian resection of a cavernous malformation. The MRI scans illustrate a relatively deep-seated cavernous malformation located in the low posterior insula. A traditional approach would involve a pterional craniotomy and transsylvian dissection.[1,6] We chose a smaller approach, which is a variant on this more classic approach.[2,3,4] The patient is positioned supine with Mayfield three-pin fixation, with a small curvilinear incision centered over the pterion slightly on the higher side to allow a trajectory looking down.

Results

Conclusion