Surgical Resection of a Cavernous Malformation of the Anterior Perforated Substance: 2-Dimensional Operative Video.

Abstract

Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.