Transcallosal-Transchoroidal Approach for A Symptomatic Third Ventricular Cavernous Malformation in A Pediatric Patient

Introduction: Cavernous malformations of the third ventricle are rare, deep-seated lesions that pose a formidable surgical challenge due to the rich, surrounding anatomy. Despite the potential morbidity of surgical treatment, the possibility of catastrophic, spontaneous hemorrhage in this location is even more feared and aggressive treatment is warranted, especially if the patient had suffered previous hemorrhages and is currently symptomatic.

Case Presentation: We demonstrate this approach on a 16-year-old boy who presented with right-sided hemiparesis (power grade 4), intense headaches, difficulties with learning and concentration, and memory loss, mainly affecting short-term memory. Patient had a previous unsuccessful excision at another center. Absence of hydrocephalus and medial thalamic location favored the transcallosal-transchoroidal approach. The head was placed in the neutral position, with a slight elevation of the vertex and the midline in vertical position. A callosotomy had already been performed during the patient's first excision attempt at another center. Upon entering the third ventricle, a mulberry-like lesion was readily identified and the cavernoma was located. The central contents of the cavernoma were dissected initially, causing relative deflation of the lesion and more maneuverability to dissect it away from the surrounding structures. Postoperative MRI showed complete resection with no signs of hemorrhage or ischemia. The patient was discharged on postoperative day 5 with no new neurological deficits. The patient was also able to return to school after one month and showed complete recovery.

Discussion: Risk to critical parietal cortical draining veins as well as the columns of the fornix and width of fornix limit access to the choroidal fissure, as well as the presence of hydrocephalus. We demonstrate a medial thalamic location favored a transcallosal-transchoroidal approach in a pediatric patient, which resulted in adequate surgical visualization and a favorable postoperative outcome.

Publication History

Article published online:
15 February 2022