Resection of Pontine Cavernoma Through the Anterior Transpetrosal Approach: 2-Dimensional Operative Video.

The pons is the most frequent local for brain stem cavernoma.1 Repeated hemorrhage of brainstem cavernoma is associated with significant and accumulative neurological deficits and thus requires treatment. According to the Swedish Karolinska's group of radiosurgery, "it could not be concluded whether GKRS affects the natural course of a CM. The incidence of radiation-induced complications was approximately seven times higher than that expected."2 Thus, microsurgical removal has become the mainstay of treatment. In our experience, the following details assist in obtaining favorable outcomes and avoiding postoperative complications3,4: (a) the entry into the cavernoma based on thorough knowledge of the microanatomy; (b) the detailed study of the images and the presentation of the cavernoma on or near the brain stem surface; (c) the resection of the live cavernous hemangioma and not the mere removal of the multiple aged organized hematomas; (d) the preservation of the associated venous angioma; (e) the direct and shortest access to the lesion provided by a skull base approach; and (f) the use of the available technology, such as intraoperative neuromonitoring and neuroimaging. We present the case of a 54-yr-old male with recent deterioration in year 2001, past repetitive episodes of gait imbalance, and speech difficulty over a 7-yr period from known pontine cavernoma. The anterior petrosal approach provided superb and direct exposure to the entry at the lateral pons and the cavernoma was totally removed with preservation of the venous angioma. His preoperative neurological deficit rapidly recovered. Patient consented to the procedure and photography. Images at 3:15 from Kadri et al, The anatomical basis for surgical presercation of temporal muscle. J Neurosurg. 2004;100:517-522, used with permission from JNSPG. Image at 3:27 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.