Endoscopic Transnasal Transclival Approach to a Pontine Cavernoma with Associated Developmental Venous Anomaly.

Background Brainstem cavernous malformations represent around 8%–22% of all intracranial cavernous malformations but exhibit a higher annual incidence of hemorrhage (2%–3%) compared with other cavernous angiomas and tend to be more symptomatic given their proximity to critical nuclei and fiber tracts. Recently, endoscopic endonasal techniques have been used for the removal of ventral skull base lesions, with significant improvement in operative morbidity and mortality compared with open approaches. Here we demonstrate the utility and feasibility of the endoscopic transclival approach for ventrally located pontine cavernomas in carefully selected patients. Case Description Consent was provided by the patient before the writing of this report. Institutional review board approval was not necessary because there was no other patient data accessed. A 21-year-old man presented to the emergency department with right-sided hemiparesis. Magnetic resonance imaging demonstrated evidence of hemorrhage from a ventrally located pontine cavernoma. Given the ventral location of the lesion and the desire for early control of an associated developmental venous anomaly (DVA), an endoscopic endonasal transclival approach was chosen. Gross total resection was achieved, and the patient did well postoperatively with no new neurologic deficits or cerebrospinal fluid leak. He is currently routinely followed and is neurologically well. Conclusions This approach provided direct visualization of the lesion and the associated DVA allowing for a gross total resection without injury to the DVA. The transclival approach may be considered as an alternative to open lateral and dorsolateral neurosurgical approaches for ventral brainstem cavernomas in carefully selected patients. Highlights • BSCMs have a higher incidence of rebleeding, with surgical management reserved for superficial lesions. • Presence of associated DVA complicates the surgery and should be taken into account when planning the approach. • Endoscopic transclival routes to the ventral brainstem allow for increased visualization of critical structures. • Main drawbacks to the transclival approach are the steep learning curve and gaining proximal control in arterial injury. • Transclival approach is a formidable tool and should be considered in select patients with symptomatic superficial BSCMs. [ABSTRACT FROM AUTHOR]