Management of Cavernous Malformation of the Cervicomedullary Junction

Abstract

Cavernous malformations located at the cervicomedullary junction represent a challenging surgical problem. Counseling and treating patients with cavernous malformations of the cervicomedullary junction requires the surgeon to understand: (1) the natural history of cavernous malformations and the risks of treatments; (2) indications for treatment; (3) local neurovascular anatomy, including safe entry points to the brainstem; (4) bony anatomy and skull base approaches to the cranio-vertebral junction; and (5) microsurgical techniques unique to the resection of cavernous malformations. Most lesions of the cranio-vertebral junction can be reached safely through the retrosigmoid, far-lateral suboccipital, and midline suboccipital approaches. The two-point method is used in conjunction with knowledge of known safe entry points to the brain stem in order to choose the appropriate approach to a particular lesion. Advances in microsurgical instrumentation, navigation, neuromonitoring, brainstem anatomy, and our understanding of cavernous malformations have all contributed to safer microsurgery for these lesions. Microsurgical resection remains the mainstay of therapy for symptomatic cavernous malformations.