Abstract
In this 3D video we review the case of a pontomesencephalic cavernous malformation in a 27-year-old woman who presented with hemiparesis and diplopia. The cavernous malformation was completely resected through a subtemporal transtentorial approach and an epitrigeminal brainstem entry zone, with a significant improvement in the patient’s hemiparesis. The relevant anatomy is reviewed in detail through multiple anatomical brainstem dissection specimens, as well as high-definition fiber tractography images. The rationale for the approach is analyzed relative to other possible options, and a number of technical pearls are provided.The video can be found here: https://youtu.be/8EoIWL7XqAc.
Highlights
The case refers to a 27-year-old female who had a fall 10 days prior to presentation, followed by progressive weakness and numbness, as well as diplopia and difficulty speaking
On physical examination she was wide awake, alert and oriented, but dysarthric, with left-sided central facial weakness and left-sided facial hemianesthesia. On examination of her extraocular movements, she could only abduct her right eye, consistent with a one-and-a-half medial longitudinal fasciculus syndrome, as well as dysfunction of the rostral interstitial nucleus of the MLF. She had left-sided hemiparesis, with the arm affected more than the leg, and left body hemianesthesia
The lesion appeared mostly hemorrhagic, but with some solid components at its inferomedial margin, which were more consistent with the popcorn appearance of a cavernous malformation
Summary
KEYWORDS subtemporal transtentorial approach; cavernous malformation; safe entry zones; brainstem anatomy; video In this video we will present the subtemporal transtentorial approach for resection of a pontomesencephalic cavernous malformation. On examination of her extraocular movements, she could only abduct her right eye, consistent with a one-and-a-half medial longitudinal fasciculus syndrome, as well as dysfunction of the rostral interstitial nucleus of the MLF.
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