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Let's talk about minimally invasive or disruptive methods, for resection of deep-seated, cavernous malformations and more specifically, a periventricular or caudate cavernous malformation. I use the subcortical parafascicular transsulcal access technique to reach the lesion. This is a 36 year-old female who presented with episodic confusion and was diagnosed with a periventricular caudate cavernous malformation. I do believe a transsulcal minimally invasive approach using a tubular retractor is quite attractive for reaching this lesion. Small right frontal craniotomy was performed. Intraoperative MRI navigation was used. A transsulcal technique was employed. Small caudectomy within the sulcus just in front of the connell suture allowed entry of the tubular retractor toward the frontal horn. The vessels at the depth of the sulcus are coagulated. I place a ventriculostomy catheter toward the lesion, but obviously not entering the lesion using navigation, small amount of brain is removed around the catheter. This creates the pathway for the tubular retractor, which is positioned in place. You can see the paraphsecular technique. The white matter tracks are displaced, and the lesion is exposed. The stylette tubing is removed and the microscope is used to remove the cavernoma utilizing the standard microsurgical techniques. The cavernoma is de-bulked and dissected from the surrounding gliotic surfaces. Some of the walls appear quite clean, obviously the frontal horn of the lateral ventricle has to be entered, as you see here, for the resection to be complete. The blind spot is usually lateral and underneath the lip of the white matter. Here you can see dynamic mobilization of the overhanging white matter, so the residual malformation is removed. Here's the entry into the fall one of the lateral ventricle. Ample amount irrigation is used to clear the debris through the ventricle. The tubular retractor is removed. You can see the minimally invasive method of reaching this deep seated lesion. And the postoperative MRI revealed minimal transgression or disruption of the white matter, and gross-total removal of the mass, and this patient made an uneventful recovery. Thank you.
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