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.
