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Medullary Cavernous Malformation

April 29, 2016


Here's a video to discuss the principles for resection of brainstem cavernous malformations, and more specifically a cavernoma within the posterior medulla oblongata. This is a 55 year-old female with hypoglossal nerve palsy and progressive swallowing difficulty. MRI evaluation revealed a sizable cavernous malformation within the posterior aspect of medulla. There is some portion of the cavernoma, which is embedded within the medulla. For resection of the brainstem cavernous malformation, the gliotic margin of the tissue is left alone to avoid development of any new neurological decline. This patient underwent a suboccipital craniotomy for resection of her cavernous malformation. The operation was conducted with the patient in the latter position using a midline incision. Following completion of this suboccipital craniotomy, the tonsils were carefully dissected. Both PICAs were identified. A fixed retractor blade was used just to hold the brain in place. You can see the cavernous malformation is readily exposed. The hematoma cavity of the lesion was entered, and the lesion was decompressed via evacuation of its clots. Next I coagulated and then carefully disconnected the pial feeding arteries, leading to the malformation. You can see these fine feeding pial vessels that are coagulated and cut. The cavernous malformation's apparent, the gliotic margin is also apparent at the tip of the arrow. Here's the body of the malformation. Here are the pial vessels joining the malformation. Any feeding vessels from the PICA should be carefully isolated and also disconnected. Here you can see the gliotic margin of the malformation, choroid plexus from the fourth ventricle. I maintain my dissection plane, just along the lesion. Here's the superior pole of the malformation that is also being isolated. Here's entry into the fourth ventricle pial feeding vessels from this part of the operative corridor, also coagulated and cut. The floor of the fourth ventricle is apparent, circumferential disconnection of the malformation continues. Here's the portion of the malformation that is embedded within the medulla. The superior pole of the malformation is now completely disconnected. The superior margin of the lesion is clearly visible. Again, ample amount of sharp dissection is used in this case. Some of the hematoma within the brain stem is also evacuated. As you can see I'm working along the perilesional gliotic margin, the lesion is now delivered. Now I inspect the resection cavity very carefully to make sure no residual lesion is apparent. You can see the developmental venous anomaly at the bed of the resection cavity that is being carefully preserved. Sharp dissection continues to disconnect the malformation piecemeal. Most of the malformation is now resected, I carefully inspect the resection cavity, especially the portion of the malformation that was embedded within the medulla to make sure no residual lesion is present in the developmental venous anomality, one of each on each wall of the medulla. Papaverine soaked Gelfoam is used to bathe the regional vessels and relieve their vasospasm. Now I enter parenchyma of the medulla and inspect the area to assure the entire part of the malformation is resected. Here you can see the gliotic margin there. Small amount of malformation that was present in this area was carefully evacuated and removed as well. You can see these white strands that belong to the malformation. These strands are carefully isolated and teased off using forceps or find bipolar pairs. Here's the gliotic margin of the resection cavity within the medulla. No obvious malformation is apparent. The developmental venous abnormalities are intact. Here's another final view of our operative corridor. The cavity is carefully irrigated, hemostasis is secured. There's another demagnified view of our operative space and the postoperative MRI revealed complete resection of the malformation without any complicating features. And this patient's swallowing difficulty actually improved after surgery. Thank you.

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