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Frontal Cavernoma: Nuances of Resection

January 07, 2015


This video is a description of resection of supratentorial, and more specifically frontal cavernous malformations. This is an 80 year old male with intractable seizures. On MRI evaluation, he harbored a typical mulberry cavernous malformation extending to the level of the ventricles. There's also associated calcification on the CT scan. Due to non eloquent locational mismalformation, a generous resection can be accomplished. The pre-lesional gliotic tissue should also be resected in order to maximize the chance of postoperative seizure freedom. He underwent the right front craniotomy. You can see the changes at the surface of the PR related to previous hemorrhages from the malformation. Superficial PR membranes were coagulated. Intraoperative image guidance and navigation were used to guide complete lesional resection as well as the pre lesional gliotic tissues. Forceps are used to coagulate the peel surfaces. Next micro scissors are used, and these are very basic standard techniques for completing resection of a large super tentorial malformation. In the case of brainstem malformations due to high eloquence of the neural structures, the pre-lesional gliotic tissues are left behind. Here you can see the mulberry appearance of the malformation. I continue to remove the lesional tissue. Here are some of the provisional gliotic structures. Next, you can see some of the recent hemorrhages associated with the cavernoma. The bipolar forceps are used as scissors, almost to disconnect the white matter surrounding the lesion. Now, there is more cavernoma apparent. Obviously the resection should extend to the level of the ventricle as expected based on the findings on preoperative MRI. Here's an entry into their frontal horn of the lateral ventricle. The ependymoma is being coagulated. This will define the most inferior border of our resection. Entry of the blood into the ventricle is avoided. I made sure the entire lesional tissue within the area of the preventrical is disconnected and removed. You can see further inspection of the resection cavity reveals northern soft cavernoma. The remaining tissues are very white and glistening, characteristic of the normal white matter. The gliotic surrounding neural tissues are also removed, and the post-operative MRI in this case demonstrated gross total removal of the lesion. And this patient has remained seizure-free since his operation. Thank you.

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