Elsevier

Surgical Neurology

Volume 56, Issue 2, August 2001, Pages 106-115
Surgical Neurology

Technique
Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem

https://doi.org/10.1016/S0090-3019(01)00529-8Get rights and content

Abstract

BACKGROUND

The natural history of brain stem cavernous malformations is unfavorable because of their high hemorrhage rate and resulting neurological deterioration among patients. However, direct surgery of intrinsic and anteriorly situated cavernomas is hazardous and leads to a bad postoperative outcome because of trauma to lateral and dorsally situated eloquent areas of the brain stem.

METHODS

We review the cases of two patients with symptomatic cavernous malformations of the anterior brain stem and describe the usefulness of a transoral-transclival approach. A 23-year-old man developed progressive hemihypaesthesia and paraesthesia, hemiparesis with gait ataxia, dysarthria, dysphonia, and dysphagia. A 38-year-old woman suffered from an acute onset of vertigo with nausea and vomiting, diplopia, and paraesthesia of the left hand and foot. In both patients, computed tomography demonstrated the presence of brain stem hemorrhage, because of cavernous malformation. Magnetic resonance imaging showed a close proximity of the lesions to the pia mater only on the ventral surface of the brain stem.

RESULTS

In both patients, the cavernomas could be safely approached and completely resected via a transoral transclival route. Three months after surgery, neurological examination revealed marked neurological improvement. The 23-year-old patient showed slight gait ataxia, no hemiparesis, no cranial nerve palsies; the 38-year-old woman demonstrated no neurological symptoms except for minimal motor dysfunction of the left hand. In both cases, under perioperative prophylactic antibiotics, no meningitis was observed. The patients could subsequently return to their previous employment.

CONCLUSION

The transoral transclival approach for ventrally situated brain stem cavernomas allows a largely atraumatic resection of the lesion.

Section snippets

Case 1

This 23-year-old man was admitted to a peripheral neurological institution with numbness, subsequent weakness of the left side on his body, and persistent singultus. Computed tomography (CT) demonstrated the presence of an intrapontine hemorrhage (Figure 1). No abnormalities were detected on the angiogram; the lesion was diagnosed clinically as a deep-seated cavernous malformation. After admission to our neurosurgical department a cranial MRI was obtained. The investigation corroborated the

Case 2

This 39-year-old woman suffered acute onset of vertigo, with nausea and vomiting, disturbance of eye movements, and numbness of the left hand and leg. MRI demonstrated a cavernous malformation in the ventral part of the medulla oblongata (Figure 6).

Discussion

Direct surgery for cavernous malformations of the brain stem is considered one of the most difficult neurosurgical operations because of the unique anatomic features of that area 3, 34. However, in the last few years we have had the opportunity to study the specific anatomy including small details in regions of interest, thanks to the development of preoperative magnetic resonance imaging 12, 32, 38. By taking into consideration the individual patho-anatomic situation we are able to plan an

References (61)

  • M.S. LeDoux et al.

    Surgically treated cavernous angiomas of the brain stemreport of two cases and review of literature

    Surg Neurol

    (1991)
  • T. Yoshimoto et al.

    Radical surgery on cavernous angioma of the brain stem

    Surg Neurol

    (1986)
  • S. Amin–Hanjani et al.

    Risks of surgical management for cavernous malformations of the nervous system

    Neurosurgery

    (1998)
  • D.J. Archer et al.

    Basilar aneurysma new transclival approach via maxillotomy

    J Neurosurg

    (1987)
  • H. Bertalanffy et al.

    Microsurgery of deep-seated cavernous angiomas. Report of 26 cases

    Acta Neurochir (Wien)

    (1991)
  • H.A. Crockard et al.

    Transoral transclival removal of a schwannoma anterior to the craniocervical junction. Case report

    J Neurosurg

    (1985)
  • O. Del Curling et al.

    An analysis of the natural history of cavernous angiomas

    J Neurosurg

    (1991)
  • P.W. Detwiller et al.

    De novo formation of a central nervous system cavernous malformationimplications for predicting risk of hemorrhage

    J Neurosurg

    (1997)
  • N. Di Lorenzo et al.

    Benign osteoblastoma of the clivus removed by a transoral approachcase report

    Neurosurgery

    (1987)
  • C.G. Drake

    Treatment of aneurysmes of the posterior cranial fossa

    Prog Neurol Surg

    (1978)
  • R. Falbusch et al.

    Surgical removal of pontomesencephalic cavernous hemangiomas

    Neurosurgery

    (1990)
  • J.L. Fox

    Obliteration of midline vertebral artery aneurysm via basilar craniectomy

    J Neurosurg

    (1967)
  • J.A. Fritschi et al.

    Cavernous malformations of the brain stem. A review of 139 cases

    Acta Neurochir (Wien)

    (1994)
  • J.M. Gomori et al.

    Occult cerebral vascular malformationshigh-field MR imaging

    Radiology

    (1981)
  • M.N. Hadley et al.

    Comperative transoral dural closure techniquesa canine model

    Neurosurgery

    (1988)
  • M.N. Hadley et al.

    The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression

    J Neurosurg

    (1989)
  • T. Hayakawa et al.

    Prevention of postoperative complications after a transoral transclival approach to basilar aneurysms. Technical note

    J Neurosurg

    (1981)
  • S. Kashiwagi et al.

    Diagnosis and treatment of vascular bran-stem malformations

    J Neurosurg

    (1990)
  • K. Kyoshima et al.

    A study of safe entry zones via the floor of the fourth ventricle for brain stem lesions. Report of two cases

    J Neurosurg

    (1993)
  • B. Liliequist

    Angiography in intracerebral cavernous hemangioma

    Neuroradiology

    (1975)
  • J. Litvak et al.

    A successful approach to vertebrobasilar aneurysms. Technical note

    J Neurosurg

    (1981)
  • J.N. Maraire et al.

    Intracranial cavernous malformationlesion behavior and management strategies

    Neurosurgery

    (1995)
  • W.F. McCormick

    The pathology of vascular (“arteriovenous”) malformations

    J Neurosurg

    (1966)
  • A.H. Menzes et al.

    Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients

    J Neurosurg

    (1988)
  • E. Miller et al.

    Transoral transclival removal of anteriorly placed meningeomas at the foramen magnum

    Neurosurgery

    (1987)
  • Y. Mori et al.

    Benign osteoblastoma of the odontoid process of the axisa case report

    Surg Neurol

    (1988)
  • Mullan S, Naunton R, Hekmat–Panah J. The use of the anterior approach to ventrally placed tumors in the foramen magnum...
  • C.S. Ogilvy et al.

    Angiographically occult arteriovenous malformations

    J Neurosurg

    (1988)
  • E. Pásztor et al.

    Transoral surgery for basilar impression

    Surg Neurol

    (1980)
  • E. Pásztor et al.

    Transoral surgery for craniocervical space-occupying processes

    J Neurosurg

    (1984)
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