Brainstem cavernous malformations (CMs) are vascular lesions characterized by dilated sinusoidal channels associated with capillary telangiectasia and developmental venous anomalies. Hemorrhages from brainstem CMs often result in focal neurological deficits, depending on the location and extent of the lesion. Surgical intervention is recommended for symptomatic or recurrent hemorrhages to prevent progressive neurological deterioration, despite the inherent risks associated with operating in highly eloquent areas of the brainstem.
Surgical approaches to brainstem CMs include retrosigmoid, far lateral, midline suboccipital with or without telovelar extension, orbitozygomatic, and supracerebellar-infratentorial approaches. For pontine and medullary CMs, the retrosigmoid, far lateral, and suboccipital craniotomies are commonly employed, with the telovelar approach being particularly favored for pontine lesions.
This study enrolled patients with brainstem CMs from three institutions who underwent surgical treatment using the telovelar approach (Figure 1). Postoperatively, all three patients demonstrated no additional neurological deficits. These findings support the safety and efficacy of the telovelar approach for treating CMs located in the pons and medulla. Herein stepwise illustration and surgical nuances are reported (Figure 2 and 3)
Figure 1. Pre- and post-operative image findings of the cavernous malformation resected via the telovelar approach.
Figure 2. stepwise illustration of the exposure of the fourth ventricle floor
Figure 3. Operative findings and surgical nuances