Ahead of Print: Endoscopic Approach to Pontine Cavernoma

Background and Importance: Hemorrhagic, symptomatic cavernous malformations in the brainstem are difficult to access. Conventional approaches such as the transpetrosal approach often require significant brain retraction. We present the successful purely endoscopic, endonasal, transclival resection of a symptomatic cavernoma located in the ventromedial pons.

Clinical Presentation: A 17-year-old male presented with acute onset of headache, facial numbness, and tingling. Magnetic resonance imaging demonstrated an enhancing lesion in the pons consistent with a cavernous malformation. Over the course of the next 3 weeks the patient had 2 additional episodes of acutely worsening neurological deficits leaving him with left-sided hemiparesis, a right 6th nerve palsy, and dysphagia. A purely endoscopic endonasal, transclival, approach was used to resect the cavernoma. Post-operatively he had a transient worsening of his left sided motor function and restricted horizontal gaze, but at last follow-up his hemiparesis had improved and his MRI demonstrated a radiographic cure. He did develop a CSF leak despite prophylactic lumbar CSF drainage for two days and use of bilateral vascularized nasoseptal flaps. The CSF leak was repaired with CSF diversion and a second surgical procedure; at last follow-up he had no recurrence of the leak.

Ahead of Print: Endoscopic Approach to Pontine Cavernoma

Background and Importance: Hemorrhagic, symptomatic cavernous malformations in the brainstem are difficult to access. Conventional approaches such as the transpetrosal approach often require significant brain retraction. We present the successful purely endoscopic, endonasal, transclival resection of a symptomatic cavernoma located in the ventromedial pons.

Clinical Presentation: A 17-year-old male presented with acute onset of headache, facial numbness, and tingling. Magnetic resonance imaging demonstrated an enhancing lesion in the pons consistent with a cavernous malformation. Over the course of the next 3 weeks the patient had 2 additional episodes of acutely worsening neurological deficits leaving him with left-sided hemiparesis, a right 6th nerve palsy, and dysphagia. A purely endoscopic endonasal, transclival, approach was used to resect the cavernoma. Post-operatively he had a transient worsening of his left sided motor function and restricted horizontal gaze, but at last follow-up his hemiparesis had improved and his MRI demonstrated a radiographic cure. He did develop a CSF leak despite prophylactic lumbar CSF drainage for two days and use of bilateral vascularized nasoseptal flaps. The CSF leak was repaired with CSF diversion and a second surgical procedure; at last follow-up he had no recurrence of the leak.

Video: Endoscopic Approach to Pontine Cavernoma

This video demonstrates surgical technique for endoscopic, endonasal, transclival resection of a pontine cavernoma.