Intracranial Cavernomas Research Articles

Multiple Cerebral Cavernous Malformation: An Unusual Cause of Vertigo.

Cerebral cavernous malformation (CM) is a rare benign vascular lesion of the brain, accounting for only 0.3-0.5% incidence in the population. Among them, only a small portion of the patients have multiple lesions (3-33%). While most lesions are asymptomatic, some patients present with seizures and hemorrhagic events. We present an atypical case of multiple cerebral CM in a patient who presented with vertigo. He did not have apparent neurological signs and symptoms until it was detected through imaging studies. His MRI showed multiple CM, with the largest lesion located in the cerebellopontine angle. A neurological consult was obtained and the patient opted for conservative treatment. He was discharged well on medications and was under active monitoring by both the neurosurgery and otorhinolaryngology teams. Intracranial cavernoma can present as vertigo without classic neurological manifestations. Any atypical presentations should alert the physician to perform further imaging to rule out sinister causes in the brain. To date, there is no reported case of intracranial cavernoma presenting as vertigo in the literature.

Gamma Knife® stereotactic radiosurgery for intracranial cavernous malformations

IntroductionGamma Knife® stereotactic radiosurgery (GKSRS) is a non-invasive alternative to surgical resection for cerebral cavernous malformations (CCMs), especially in eloquent locations. MethodologyA retrospective review was performed on an Australian cohort of patients receiving GKSRS for CCMs at a single institution. All patients exhibited symptoms and/or radiological evidence of haemorrhage before therapy. The minimum follow-up was 1-year post-GKSRS. McNemar’s test was used for differences in matched-pair outcomes pre- and post-GKSRS with an α = 0.05. A systematic review and meta-analysis was additionally performed to synthesise the current published evidence on the clinical efficacy of stereotactic radiosurgery in reducing haemorrhage risk in CCMs using a DerSimonian and Laird random effects model. ResultsThirty-five patients (39 cavernomas) underwent GKSRS. 87.2 % of patients had evidence of at least one haemorrhage before GKSRS and the remainder exhibited seizures. The median dose was 12.5 Gy in a single fraction (IQR 12–13). The median follow-up duration from GKSRS was 809 days (IQR 536–960). There was a significant reduction in matched annual bleed rate from pre-GKSRS (52.1 %) compared to after SRS (12.3 %) (p < 0.001) [OR = 0.07, 95 % 0.008–0.283] There was no statistically significant difference in seizure incidence pre- (30.7 %) versus post-GKSRS (17.9 %) (p = 0.13) [OR = 0.167, 95 %CI 0.004–1.37]. One patient (3 %) with a brainstem lesion experienced long-term treatment-related oedema with persistent ipsilateral weakness and tremors. On meta-analysis of 25 pooled studies, radiosurgery for the treatment of CCMs was associated with a statistically significantly relative risk (RR) reduction in haemorrhage events [random effects RR 0.12 (95 % CI 0.074–0.198), p < 0.001)], with most of the proportionate risk reduction occurring in the initial 2 years following SRS. ConclusionGKSRS significantly reduces the annual rate of haemorrhage for intracranial cavernomas in this cohort and on meta-analysis, particularly in the first 2 years following treatment. The overall risk of treatment-related morbidity is low.

A 5-year outcome of propranolol for the treatment of paediatric intracranial cavernoma: case report and a review of the literature.

We describe a case of a young male patient with KRIT1-driven familial cavernous malformation syndrome who developed multiple brain cavernomas, intracranial bleeding, and persistent seizures. Due to the relentless growth of cavernous malformations and recurrent intracranial bleeds, it was decided to enrol the patient in the "Propranolol for Intracranial Cavernoma" (PICC) pilot trial at our institution. Over the 5-year treatment period with 20 to 40-mg oral propranolol three times daily (TDS), we noted the near-complete arrest of the growth of cavernous malformations with no further evidence of intracranial bleeding or any further seizures. The observed outcome is consistent with the extremely limited published literature on the topic; thus, this case provides important evidence that supports the use of propranolol as a prophylactic treatment for paediatric intracranial cavernomas. We strongly encourage and recommend future prospective randomised controlled trials to definitively assess and characterize the therapeutic utility of propranolol in this patient population.

Impacting the Treatment of Highly Eloquent Supratentorial Cerebral Cavernous Malformations by Noninvasive Functional Mapping-An Observational Cohort Study.

Cerebral cavernous malformations (CCM) may cause cavernoma-related epilepsy (CRE) and intracranial hemorrhage (ICH). Functional mapping has shown its usefulness during the resection of eloquent lesions including the treatment of brain arteriovenous malformations. To evaluate the impact of noninvasive functional mapping on decision-making and resection of eloquently located CCM. Of 126 patients with intracranial cavernomas, we prospectively included 40 consecutive patients (31.7%) with highly eloquent CCM between 2012 and 2020. We performed functional mapping via navigated transcranial magnetic stimulation (nTMS) motor mapping in 30 cases and nTMS language mapping in 20 cases. Twenty patients suffered from CRE. CCM caused ICH in 18 cases. We used functional mapping data including function-based tractography in all cases. Indication toward (31 cases) or against (9 cases) CCM resection was influenced by noninvasive functional mapping in 36 cases (90%). We resected CCMs in 24 cases, and 7 patients refused the recommendation for surgery. In 19 and 4 cases, we used additional intraoperative neuromonitoring and awake craniotomy, respectively. Patients suffered from transient postoperative motor or language deficits in 2 and 2 cases, respectively. No patient suffered from permanent deficits. After 1 yr of follow-up, anti-epileptic drugs could be discontinued in all patients who underwent surgery but 1 patient. Surgery-related deficit rates are low even for highly eloquent CCM and seizure outcome is excellent. The present results show that noninvasive functional mapping and function-based tractography is a useful tool for the decision-making process and during microsurgical resection of eloquently located CCM.

Virtual endoscopy assisted pure ventriculoscopic resection of cavernomas occluding foramen of Monroe: Technical note and literature review

ObjectiveCavernomas at Foramen of Monroe (FoM) are rare cases among the intracranial cavernomas. Pure ventriculoscopic removal of cavernoma at FoM through a single burr hole is challenging and rarely reported. MethodsWe herein introduced the virtual endoscopy (VE) assisted ventriculoscopic resection to treat the cavernomas at FoM. Two cases diagnosed with cavernomas at FoM, a 31-year-old male patient (case 1) and a 26-year-old male patient (case 2), were included. Both of them suffered from headache, nausea and vomiting. The pre-operative MRI revealed masses at the FoM. We reconstructed the VE on a free and open-source platform (3D Slicer) for the pre-surgical evaluation. And then ventriculoscopic operation through a single burr hole was made to remove the cavernomas at FoM. ResultsThe VE displayed a 14×19×16 mm lesion in case 1 and an 18×20×29 mm lesion in case 2 and both cases revealed some attachment between the lesions and the periventricular tissue. The ventriculoscopic operations indicated by VE were performed to achieve total resection of the cavernomas without neurological deficit. ConclusionsAlthough the neuroendoscopic treatment to cavernoma at FoM through a single burr hole was rarely reported among the previous literatures, it was a quite effective and useful method in our cases. And the application of VE before ventriculoscopic operation could help to provide a three-dimensional and panorama view of the intraventricular lesions.

Management of A Cerebral Cavernoma During Pregnancy: Case Report

Intracranial cavernoma is a vascular malformation composed of thin-walled vascular vessels. Blood flow in these lesions is much lower than in AVMs and their hemorrhages are usually small. The presentation is often subacute with seizures or focal neurological deficit, which can be confused in pregnant women with pregnancy toxaemia especially if the malformation is bleeding. We report the case of a 35-year-old patient , 30 weeks pregnant , admitted for delivery who presented with acute intracranial hypertension syndrome with obnubilation of consciousness. Emergency brain CT showed a right fronto-parietal intracranial hematoma. MRI with angiographic sequences show a left parietal hematoma without visible arteriovenous malformation. The patient underwent emergency surgery to evacuate her intracranial hematoma, then the patient was transferred to a gynecological unit for emergency fetal extraction. Histo-pathological analysis of the removed fragments showed an intracranial cavernoma appearance. Urgent surgical evacuation is only necessary if the prognosis is vital.

Endoscopic Paramedian Sitting Craniotomy for Resection of a Dorsal Midbrain Cavernous Malformation: 2-Dimensional Operative Video

This case video demonstrates the surgical technique for resection of a cavernous malformation in the right dorsal midbrain. This video was deemed exempt by the University of Pennsylvania Institutional Review Board (IRB), as it is considered a case report, which does not require IRB approval or patient consent. The patient was a 57-yr-old male with cerebral cavernous malformation syndrome with multiple intracranial cavernomas. He was noticed to have progressively slowed speech with worsening confusion and drowsiness. On exam, the patient exhibited worsening in swallowing and upward gaze paresis, secondary to Parinaud phenomena. The patient was treated with microsurgical resection, utilizing stereotactic navigation and intraoperative neurophysiologic monitoring. Intraoperative view provided in the video was captured using a Karl Storz Endoscope (Karl Storz SE & Co KG, Tuttlingen, Germany). Postoperatively, the patient had worsening double vision, which improved on follow-up, in addition to improvement in sensorium and swallowing.

Cavernoma-related epilepsy in cavernous malformations located within the temporal lobe: surgical management and seizure outcome

Cavernoma-related epilepsy (CRE) is a frequent symptom in patients with cerebral cavernous malformations (CCMs). Reports on surgical management and seizure outcome of epileptogenic CCM often focus on intracranial cavernoma in general. Therefore, data on CCMs within the temporal lobe are scarce. The authors therefore analyzed their institutional data. From 2003 to 2018, 52 patients suffering from CCMs located within the temporal lobe underwent surgery for CRE at University Hospital Bonn. Information on patient characteristics, preoperative seizure history, preoperative evaluation, surgical strategies, postoperative complications, and seizure outcome was assessed and further analyzed. Seizure outcome was assessed 12 months after surgery according to the International League Against Epilepsy (ILAE) classification and stratified into favorable (ILAE class I) versus unfavorable (ILAE classes II-VI). Overall, 47 (90%) of 52 patients with CCMs located in the temporal lobe and CRE achieved favorable seizure outcome. Pure lesionectomy was performed in 5 patients, extended lesionectomy with resection of the hemosiderin rim in 38 patients, and anterior temporal lobectomy in 9 patients with temporal lobe CCM. Specifically, 36 patients (69%) suffered from drug-resistant epilepsy (DRE), 3 patients (6%) from chronic CRE, and 13 patients (25%) sustained sporadic CRE. In patients with DRE, favorable seizure outcome was achieved in 32 (89%) of 36 patients. Patients with DRE were significantly older than patients with CCM-associated chronic or sporadic seizures (p = 0.02). Furthermore, patients with DRE more often underwent additional amygdalohippocampectomy following the recommendation of presurgical epileptological evaluation. Favorable seizure outcome is achievable in a substantial number of patients with epileptogenic CCM located in the temporal lobe, even if patients suffered from drug-resistant CRE. For adequate counseling and monitoring, patients with CRE should undergo a thorough pre- and postsurgical evaluation in dedicated epilepsy surgery programs.

Pattern and Management of Intracranial Cavernoma

Pattern and Management of Intracranial Cavernoma

Cervical Intramedullary Cavernoma in Children: Case report and literature review

Case presentation: A 10-year-old male patient was admitted due to posterior cervicalgia, vomiting and progressive generalized weakness. Physical examination showed difficulty in ambulation and tetraparesis. Magnetic resonance imaging (MRI) of the cervical medulla enhanced by the contrast agent, gadolinium, showed a poorly contrasted mass with a hemorrhagic center. We undertook a posterior cervicotomy (C1-C3). Post-operative evolution was satisfactory with complete regression of the deficits 90 days after surgery. Control MRI at intervals of 1 and 4 years confirmed absence of the tumor. Discussion: Cavernomas are vascular malformations, consisting of coarsely dilated vascular channels and coated by a single layer of endothelial cells, devoid of endothelium and myothelium. They represent only 5-12% of all vascular pathologies of the medulla, with only 10% affecting the pediatric population. There are only thirty cases of pediatric intramedullary spinal cavernomas in the literature, with predominance among males (2.1:1). Thoracic and cervical spinal cavernomas consist in 55% and 45% of the cases, respectively. In six cases (20%) cavernomatous lesions were associated with synchronic intracranial cavernoma. Among the reported cases, only one had poor evolution after surgery, whereas six patients persisted with prior symptoms. Conclusion: Spinal intramedullary cavernomas are rare entities, especially in the pediatric population, and are treated with surgery which improves prior neurologic deficits, besides preventing rebleeding

Resection of anterolateral midbrain cavernous malformation via orbitozygomatic transsylvian pretemporal approach with uncal resection.

Brainstem cavernomas are benign, angiographically occult, low-flow lesions and constitute 18%–35% of intracranial cavernomas.4,6 They are known to have an annual rupture risk of 2%–6%,2,5 and once symptomatic, they frequently cause progressive neurological morbidity. A 22-year-old lady presented with progressive profound neurologic deficits from three distinct hemorrhages over 2 months. Surgery was indicated given the aggressive natural history, and the lesion now presented to the surface with displacement of corticospinal tracts noted on diffusion tensor imaging.1,7 We describe a surgical technique via an orbitozygomatic transsylvian pretemporal approach with uncal resection to open the oculomotor-tentorial window and resect the lesion.3The video can be found here: https://youtu.be/j5yYp4OsaRc.

Cervical Intramedullary Cavernoma in Children: case report and literature review

Case presentation: A 10-year-old male patient was admitted due to posterior cervicalgia, vomiting and progressive generalizedweakness. Physical examination showed difficulty in ambulation and tetraparesis. Gadolinium-loaded magnetic resonance imaging(MRI) of the cervical medulla, showed a poorly contrasted mass with a hemorrhagic center. We undertook a posterior cervicotomy(C1-C3). Post-operative evolution was satisfactory with complete regression of the deficits 90 days after the surgery. Control MRIat intervals of 1 and 4 years confirmed absence of the tumor. Discussion: Cavernomas are vascular malformations, consisting ofcoarsely dilated vascular channels and coated by a single layer of endothelial cells, devoid of endothelium and myothelium. Theyrepresent only 5-12% of all vascular pathologies of the medulla, with only 10% affecting the pediatric population. There are onlythirty cases of pediatric intramedullary spinal cavernomas in the literature, with predominance among males (2.1:1). Thoracic andcervical spinal cavernomas consist in 55% and 45% of the cases, respectively. In six cases (20%) cavernomatous lesions were associatedwith synchronic intracranial cavernoma. Among the reported cases, only one had poor evolution after surgery, whereas six patientspersisted with prior symptoms. Conclusion: Spinal intramedullary cavernomas are rare entities, especially in the pediatric population,and are treated with surgery which improves prior neurologic deficits, besides preventing rebleeding.

Intracranial Cavernomas: An Institutional Review

Introduction Intracranial cavernomas are rare vascular malformations accounting for 0.4 to 0.8% of all intracranial lesions. They usually present with seizures and neurological deficits following hemorrhagic episode. Surgical excision can provide lifetime cure from these lesions. Aims and Objectives The aims and objectives of this study were to study the clinicopathological profile and discuss management strategies affecting the outcome of patients with intracranial cavernomas. Materials and Methods We have studied patients of intracranial cavernomas operated in our department in the past 5 years. Magnetic resonance imaging of the brain was used as diagnostic modality of choice. Patients' clinical status upon admission and accessibility of the lesion were taken into account for surgical planning. Observation and Results Most of the patients were young. Twenty-two patients had single and 6 patients had multiple lesions. Patients with supratentorial lesions mainly presented with seizures (75%) wherein infratentorial lesions had cranial nerve palsies and long tract signs (25%). Total surgical excision was achieved in all the patients. No significant postoperative complications were encountered. None of the patient showed recurrence during follow-up period. Conclusion Patients benefit from modern neurosurgical techniques in contrast to conservative approach in this disease of rather prolonged and unpredictable natural course.

Abstract WMP117: Conservative versus Surgical Treatment for Brainstem Cavernous Malformation.

Brainstem cavernous malformation (BCM) account for 8-22% of all intracranial cavernomas. Currently, they can be treated microsurgically or conservative but it is still difficult to choose the best treatment for each patient. The main objective of our series was to evaluate the long-term functional outcome and recurrence in patients with BCM treated with conservative or surgical treatments. Hypothesis: We assessed the hypothesis that surgical and conservative treatments are associated with different functional outcome and re-hemorrhage rate in long-term follow-up. Methods: In this non-randomized, clinical series, we compared the clinical and radiological findings of patients with their first hemorrhage secondary to confirmed BCM, treated in a tertiary neurological center, during a twenty five- year period. Treatment of each patient was selected by the attending physician and consisted of either conservative or surgical evacuation of BCM. The primary end-points were recurrent hemorrhage and functional outcome. Favorable prognosis was defined as modified Rankin scale (mRs) of 0 to 2. Results: From January of 1990 to July of 2015; 99 patients with BCM hemorrhage were treated (59 [59,6%] female; mean age 37± 13 years). 37 patients (37,4%) were surgically treated and 62 (62,6%) received conservative treatment. During the follow-up; 20 patients in the medical group (median time of recurrence: 34,5 months; IQR: 13,75-93) and 4 patients in the surgical group (median time of recurrence: 22 months; IQR: 9-46,5) had a recurrence (OR: 0,255; 95% IC: 0,079-0,817), with a cumulative incidence of 5,1 per 100 years-person and 3,96 per 100 years-person respectively. Because of rebleeding, 11 patients of the conservative group were taken to surgery and 3 of the surgical group were to required re-intervention. At the end of follow-up (median: 51 months; IQR: 19-104) 51 patients remained in the conservative group and 28 (54,9%) had a favorable mRs. 48 patients remained in the surgical group and 27 (56,2%) had a favorable mRs (OR:0,94 95% IC: 0,42-2,09). Conclusion: Despite a significant high recurrent hemorrhage rate was observed in conservative treated patients, we did not found difference in clinical outcome between both groups of patients with BCM.

The Clinical Features and Surgical Approaches for Brain Stem Cavernomas

Introduction Cavernous malformations localized in the brain stem are considered as a separate entity in relation to other intracranial cavernoma. Clinical presentation is specific in terms of focal neurologic deficit; they show aggressive biological behavior and unfavorable clinical course, whereas localization in the brain stem naturally represents the largest surgical problem and challenge and significantly higher operational risk. Results We report a series of 10 patients with brainstem cavernoma, operated at the Department of Neurosurgery, Clinical Center of Serbia, between 2008 and 2012. In cavernous lesions of the dorsal pons and upper cerebellar peduncle, we used the approach through the fourth ventricle; in the laterally localized pontine cavernoma, we used the cerebellopontine angle approach, and in the cavernoma localized in the central midbrain tegmental area, we used the supracerebellar infratentorial approach. Conclusion Surgical removal of the brainstem cavernoma is absolutely expedient both from the standpoint of preventing recurrent and debilitating hemorrhage and in terms of recovery of neurologic deficit. In patients with disturbed vital functions, the evacuation of the hematoma and removal of the malformation eliminate compression of effects on vital structures of the brain stem. Keywords brain stem; cavernomas; approach

The microsurgical solution in supratentorial cavernous angiomas

Cavernous angiomas of the central nervous system are rare, neurovascular lesions usually detected in patients aged 20-50 and represent up to 8-15% of all intracranial malformations. The association between cavernomas and arteriovenous malformations is met in 10-30% of cases. Treatment strategies for intracranial cavernomas include conservative management, open microsurgery and finally stereotactic radiosurgery (the use of which is still highly debatable as there are no available methods to determine its short term effects). The authors present their surgical experience in what regards a cohort of 149 consecutive patients, diagnosed with intracranial and supratentorial cavernomas, admitted, investigated and treated between January 2000 and January 2015. The clinical particularities of the patients together with the surgical approaches are debated. Last but not least the outcome and quality of life of the patients is discussed.

Multimodal management in intracranial cavernous angiomas (intracranial cavernomas). An experience of 99 cases

Introduction. Intracranial cavernomas are rare neurovascular lesions, met frequently in patients with anomalies of the vasculature of the encephalon and medulla. Cavernomas account for 0.02-0.53% of all intracranial lesions and approximately 8-15% of all intracranial vascular malformations. A procentage of about 10-30% of all cases show an association between cavernomas and arteriovenous malformations. Clinically, the lesions become symptomatic when their size becomes larger than 1cm. The symptoms include headache, seizures, focal neurologic deficit and last but not least hemorrhage. Materials and methods. The authors present a study of 99 patients diagnosed and treated for intracranial cavernomas between January 2004 and January 2015 (11 years). The study encompasses 45 male patients and 44 female patients with ages ranging between 11 and 56, all treated at the Bagdasar-Arseni Emergency University Hospital in Bucharest, Romania. A large percentage of the cavernomas were supratentorial 72 cases (72.72%), while only 27 tumors were positioned in the infratentorial compartment of the skull. Regarding the position of the cavernomas, 29 of them (40.27%) were in the frontal lobe, 13 (18.05%) were in the parietal lobe, 20 (27.7%) were in the temporal lobe, while 3 were in the occipital lobe (4.16%). Infratentorial tumors affected the brainstem in 17 cases (62.9%) while 10 cases showed cerebellar implication (37.03%). There were 7 patients in which the authors described multiple cavernomas. The clinical onset was represented by seizures in 59 cases (59.59%), hemorrhage in 20 cases (20.20%) and focal neurologic deficit in 13 cases (13.13%). The symptoms consisted of seizures in 63 cases (63.63%), focal neurologic deficit in 16 cases (16.16%) and hemorrhage in 23 cases (23.23%) while 9 cases (9.9%) were completely asymptomatic. The authors chose to practice a conservative management for the 7 cases with multiple lesions, the 9 asymptomatic cases and 5 cases with deep positioning. In the 5 cases with deep cavernomas the patients were subjected to gamma knife stereotactic radiosurgery but only 2 patients showed response to treatment. Results. In the 99 patients presented by the authors, out of the 76 cases operated, a number of 57 interventions (75%) managed to completeley remove the lesion and perilesional gliosis. A number of 19 interventions only managed to remove the tumor as perilesional gliosis was impossible to remove without lesions to eloquent areas. Conclusions. Intracranial cavernomas are rare lesions, usually incriminated when seizures appear. When they are asymptomatic the best option for the surgeon is to wait and see how the tumor behaves. When seizures appear in the array of symptoms of a given tumor the best prognosis is offered by lesionectomy with the removal of perilesional gliosis. Neuronavigation guided surgery has managed in most cases to facilitate complete removal of such tumors and to avoid postoperative defficit with the improvement of clinical results. Furthermore, neuronavigation removes the necessity of an unpleasant stereotactic frame. When intracerebral hemorrhage occurs, surgery is mandatory and represents a neurosurgical emergency. In multiple tumors, the bleeding cavernoma must be removed. The effectiveness of Gamma Knife Surgery (GKS) is debatable.

RADIOSURGERY OF INTRACEREBRAL CAVERNOMAS--CURRENT INTERNATIONAL TRENDS

Although still a controversial management option, radio-surgery of intracranial cavernomas has become increasingly popular world-wide during the last decade. Microsurgery is a safe and effective treatment for symptomatic hemispheric cavernomas. However, the indication for microsurgical resection of deep eloquent cavernomas is relatively limited even in experienced hands. The importance of radiosurgery has recently been appreciated in parallel with increasing positive experiences both in terms of effectiveness and safety, especially for cases high risk for surgical resection, in the brainstem, thalamus and basal ganglia. While radiosurgery was earlier indicated mainly for surgically inaccessible lesions that had bled multiple times, a more proactive policy has recently become more accepted. In our opinion preventive treatment with the low morbidity radiosurgery serves the patients' interest especially for deep eloquent lesions that had bled not more than once, due to the cumulative morbidity of repeated hemorrhages. Despite our increasing knowledge on natural history, there is currently no available treatment algorithm for cavernomas. Arguments for all three treatment modalities (observation, microsurgery and radiosurgery) are established, but their indication criteria are yet to be defined. It is time to organize a prospective population based data collection in Hungary, which appears to be the most realistic way to clarify indication criteria.

Cavernous malformations of the brain stem - the clinical features and surgical approaches

Introduction. Cavernous malformations localized in the brain stem are considered as a separate entity in relation to other intracranial cavernoma. Clinical presentation is specific in terms of focal neurologic deficit, they show aggressive biological behavior and unfavorable clinical course, whereas localization in the brain stem naturally represents the largest surgical problem and challenge and significantly higher operational risk. Results. We report a series of 10 patients with brainstem cavernoma, operated at the Department of Neurosurgery, Clinical Center of Serbia in the period of 2008-2012. In cavernous lesions of the dorsal pons and upper cerebellar peduncul we used the approach through the fourth ventricule, in the laterally localized pontine cavernoma we used the cerebellopontine angle approach, in the cavernoma localized in the central midbrain tegmental area was used supreacerebellar infratentorially approach. Conclusion. Surgical removal of the brainstem cavernoma is absolutely expedient both from the standpoint of preventing recurrent and debilitating hemorrhage and in terms of recovery of neurologic deficit. In patients with disturbed vital functions, the evacuation of the hematoma and removal of the malformation eliminate compression of effects on vital structures of the brain stem.

A patient with short term memory problems and ataxia

A patient with short term memory problems and ataxia