June 09, 2015
This is a relatively short video discussing tenance for resection of basal ganglia or insular cavernous malformations. This is a 22 year-old female who presented with progressive hemiparesis and was noted to have gradual growth of hair, left sided basal ganglia cavernous malformation on imaging. MRI evaluation demonstrates the sequential growth of this cavernous malformation, just along the insular as well as the striatum. She subsequently underwent left front temporal craniotomy. Here's is the extent of the exposure and the left Sylvian fissure. Arachnoid knives were used for superficial dissection. The fissure was split widely. Here are the M2 branches. In this case I used direct modal cortex stimulation mapping during dissection of the cavernoma to monitor the descending motor tracks. Here you can see the inside to outside technique for dissecting the fissure, a method I have described at multiple occasions during these videos. The fissure was very adherent in this young patient. Dissection continues again from deep to superficial. Here's the dissection along the sphenoidal segment or the anterior limb of the Sylvian fissure. Here's the M1 and the bifurcation. Here's use of direct MEPs, direct motor evoked potentials, for monitoring the motor pathways. Navigation guided the corticotomy within the insula between the M2 and M3 branches. The cavernoma was encountered, was debarked and silicone freshly dissected. The lenticular straight arteries were carefully protected as you can see within the posterior aspect of the resection cavity. Their temporary occlusion revealed changes in our MEPs. Therefore perforators were noted to be important and were protected during the entire dissection. I worked between these perforating vessels to evacuate the hematoma and also remove the malformation. Here you can see the hematoma that is being evacuated so that the malformation can be delivered. Piecemeal removal continued until normal appearing gliotic white matter was encountered. There is some venous bleeding that was rarely controlled. Here you can see a relatively gliotic margin at the end of our resection. The superior pole of their lesion can be specially problematic and challenging to remove, since it's hiding underneath the frontal opercular. This portion of malformation was delivered into a resection cavity after the hematoma was evacuated. Here's the gliotic margin or the malformation. Here's the wall of, or the capsule of the malformation. I continue to work around the malformation and remove it piecemeal. You can see this is somewhat along the posterior aspect of the Sylvian fissure. The final pieces of the malformation that is being removed. Here's the final operative space. A de magnified view of the corridor. And the post-operative MRI in this case demonstrated relatively good removal of the cavernoma. This patient's hemiparesis worsened after surgery, but ultimately improved significantly. Thank you.
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