Endoscopic Transclival Approach to Brainstem Cavernomas: Our Preliminary Experience and the Role of Diffusion Tensor Imaging with Tractography

Introduction: Brainstem cavernous malformations are benign subset of cerebral cavernous malformations, but their annual incidence of hemorrhage is higher (2–3%) than other cavernous angiomas and tend to be more symptomatic given their proximity to critical fiber tracts. According to scientific literature, both endoscopic endonasal and diffusion tensor imaging techniques have been used for the removal of ventral skull base lesions, with significant improvement in morbidity and mortality.

Methods: 3 cases of patients with evidence of hemorrhage from a ventrally located pontine cavernoma, treated with an endoscopic endonasal transclival approach in the last two years were retrospectively reviewed; clinical-radiological findings, recurrence rate, surgical technique and radicality were analyzed. In all cases tractography with diffusion tensor imaging (DTI), magnetic resonance imaging (MRI), frameless stereotactic navigation, and intraoperative neuromonitoring was used.

Results: In all cases hemiparesis was the major clinical onset. Gross total resection was achieved. None of the patients experienced major complications. In 1 case a transient worsening of preoperative neurological deficits occurred (facial nerve palsy, hemiplegia and strabism) with subtotal resolution within 8 weeks. No direct injury to the surrounding neurovascular structures nor cerebrospinal fluid leak were observed. Postoperative neuroimaging confirmed complete removal and patients were routinely followed up by the ENT with a 1–2 and 4 week post operative outpatient endoscopic control.

Conclusions: Our analysis showed that, in carefully selected patients, the endoscopic transclival approach for ventrally located pontine cavernomas, is feasible and safe and potentially improves surgical outcomes and resection. The use of Preoperative diffusion tensor imaging in patients undergoing surgical resection could represent an additional tool to increase radicality and select the best surgical strategy for this challenging anatomical area.

Publikationsverlauf

Artikel online veröffentlicht:
05. Februar 2024