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Transmastoid presigmoid retrolabyrinthine approach for removal of pontine cavernous malformation: how I do it

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

Bleeding of brainstem cavernous malformations (BSCM) cause high morbidity and should be treated surgically whenever possible.

Method

We present a 56-year-old man, who was diagnosed with a BSCM at right pons, which caused functional impairments of dorsal column, spinothalamic tract, cochlear nucleus, and middle cerebellar peduncle. A transmastoid presigmoid retorlabyrinthine approach via the lateral pontine zone (LPZ), with an assistance of imaging guidance and intraoperative neurophysiological monitoring, was performed to completely resect the BSCM. The patient recovered despite a transient worsening of cerebellar sign and hemiparesthesia for 1 week, without surgical complications.

Conclusions

A transmastoid presigmoid retrolabyrinthine approach through LPZ is safe and effective for lateral pontine BSCM resection.

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Abbreviations

BSCM:

Brainstem cavernous malformation

CPA:

Cerebellopontine angle

CSF:

Cerebrospinal fluid

CN:

Cranial nerve

CT:

Computed tomography

IONM:

Intraoperative neurophysiological monitoring

LPZ:

Lateral pontine zone

MRI:

Magnetic resonance imaging

SCC:

Semicircular canal

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan

    Yu-Chiang Yeh, Kuo-Chen Wei & Ko-Ting Chen

  2. Ph.D. Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan

    Ko-Ting Chen

Authors
  1. Yu-Chiang Yeh
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  2. Kuo-Chen Wei
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  3. Ko-Ting Chen
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Corresponding author

Correspondence to Ko-Ting Chen.

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Conflict of interest

The authors declare that they have no conflict of interest.

Patient consent

The patient has consented to the submission of this How I Do It for submission to the journal.

Additional information

Summary of 10 Key Points

1. Transmastoid presigmoid retrolabyrinthine approach is the shortest route and provide direct approach to lateral pontine zone of brainstem.

2. Lateral pontine zone is a safe entry zone to resect lateral pontine lesions.

3. Transmastoid approach without a need of craniotomy is efficient and effective in selected cases.

4. Neuronavigation system incorporating with high resolution CT (temporal bone) and brain MRI provides valuable anatomical information in petrosal approach for BSCMs.

5. Intraoperative neurophysiological monitoring provides valuable physiological information before, during, and after BSCM removal.

6. Temporalis fascia graft is useful to close presigmoid dura defect.

7. Tissue glue provides extra-support to prevent CSF leakage.

8. Bone wax should be used to cover the drilled rough surface of petrous bone.

9. A generous fat graft should be harvested to plug into the drilled aeration dead space, which provides support to dura graft and decreases risk of CSF leakage and CNS infection.

10. A cosmetic mastoid cortical bone reconstruction is suggested.

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This article is part of the Topical Collection on Neurosurgical technique evaluation

Electronic supplementary material

ESM 1

Photos taken by neuronavigation system after dura was opened. (A) Bone window of brain CT confirmed the location of semicircular canal and a retrolabyrinthe approach. (B) Brain MRI confirmed the LPZ, which provides the shortest distance to the cavernoma. (PNG 984 kb)

High resolution image (TIF 3415 kb)

ESM 2

Subcortical motor evoked potential for detecting fiber tracts of CN6,7 (upper 2 rows), upper limbs (middle 2 rows) and lower limbs (lower 2 rows). No active response could be generated by 3 mA stimulation; while all except anterior tibialis muscle response could be generated by 5 mA stimulation. (PNG 495 kb)

High resolution image (TIF 4324 kb)

ESM 3

Left upper limb somatosensory evoked potential did not change through the whole surgery (upper graph). Bilateral auditory brainstem response (ABR) shows a decline of ABR at right side before entering into pons, suggesting a decrease of cochlear function resulted from bleeding cavernoma, and the waveform did not change bilaterally through the whole surgery (lower graph). (PNG 558 kb)

High resolution image (TIF 3923 kb)

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Yeh, YC., Wei, KC. & Chen, KT. Transmastoid presigmoid retrolabyrinthine approach for removal of pontine cavernous malformation: how I do it. Acta Neurochir 162, 1131–1135 (2020). https://doi.org/10.1007/s00701-020-04263-3

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  • DOI: https://doi.org/10.1007/s00701-020-04263-3

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