Abstract
Background:
Approximately 14% of cavernous malformations (CMs) occur in the medulla oblongata,
where their proximity to vital neural structures makes surgical intervention challenging.
Anatomical variations, such as an arcuate foramen (AF), a bony canal that encases
the vertebral artery (VA), may further complicate surgery by obstructing the surgical
view during exposure of the anterolateral surface of the medulla and by restricting
VA mobilization, which may be necessary in some cases. We present a novel case of
a medullary CM coexisting with an AF, which required tailored surgical strategies
for safe and effective resection. To our knowledge, this is the first report to document
this combined pathology, accompanied by a surgical video.
Methods: A 25-year-old male presented with right dense hemiparesis. MRI revealed a
large hemorrhagic medullary CM. The patient underwent a left far-lateral transcondylar
approach for resection of the CM.
Results: The AF was encountered intraoperatively and had to be unroofed to achieve
an adequate surgical trajectory. Gross total resection was achieved, and the patient
made an excellent recovery without postoperative neurological deficit.
Conclusion: The far-lateral approach provides excellent access for resection of anterior
medullary CMs. This case highlights the importance of detailed preoperative planning,
intraoperative strategy, and real-time navigation, particularly when anatomical variations
such as the AF are present. Although the AF may hinder exposure and require tailored
adjustments, it does not inherently complicate the entire procedure unless vertebral
artery mobilization results in vascular injury.
