Cavernous Malformations in and Around the Third Ventricle: Indications, Approaches, and Outcomes

Abstract

BACKGROUND Cavernous malformations in structures in and around the third ventricle are a challenging conceptual and surgical problem. No consensus exists on the ideal approach to such lesions. OBJECTIVE To perform a retrospective review of our institutional database to identify and evaluate approaches used to treat cavernous malformations located in and around the third ventricle. METHODS Information was extracted regarding lesion size and location, extent of resection, time to last follow-up, surgical approach, presenting symptoms, preoperative and postoperative neurological status, and specific approach-related morbidity. RESULTS All 39 neurosurgical operations (in 36 patients) were either an anterior interhemispheric (AIH) (44%, 17/39) or a supracerebellar infratentorial (SCIT) (56%, 22/39) approach. Gross-total resection was achieved in 23 of 39 procedures (59%), a near-total resection in 1 (3%), and subtotal resection in 15 (38%). For the 31 patients with at least 3 mo of follow-up, the mean modified Rankin Scale (mRS) score was 1.5. Of the 31 patients, 25 (81%) had an mRS score of 0 to 2, 4 had a mRS score of 3 (13%), and 1 each had a mRS score of 4 (3%) or 5 (3%). CONCLUSION Most approaches to cavernous malformations in and around the third ventricle treated at our institution have been either an AIH or a SCIT approach. The AIH approach was used for lesions involving the lateral wall of the third ventricle or the midline third ventricular floor, whereas the SCIT approach was used for lesions extending from the third ventricle into the dorsolateral midbrain, with acceptable clinical results.

A Case of Cavernous Malformation of the Midbrain Removed via an Interhemispheric Transcallosal Subchoroidal Approach

“…For the above reasons, in the current case, a subchoroidal approach was used to enter the third ventricle through the lateral ventricle to avoid damage to the fornix and internal cerebral vein because the lesion existed in the posterior two-thirds of the third ventricle. 17) In the current case, postoperative cognitive dysfunction was observed temporarily 3 weeks after surgery. MRI showed a high-intensity area in the corpus callosum and the right anterior thalamus on DWI and FLAIR, suggesting the influence of compression of the thalamus with a brain spatula, 1 week postoperatively.…”

“…16) Three routes of entry were observed from the lateral ventricles into the third ventricle: the transforaminal, the transchoroidal, and the subchoroidal approaches. 17) The transforaminal approach is associated with a risk of fornix or internal cerebral vein injury and is difficult to use except in cases with a cave of the septum pellucidum. The transchoroidal and the subchoroidal approach are both approaches via the choroidal fissure.…”

Surgical resection of intracranial cavernous hemangioma located at uncommon location: Clinical presentation and management

“…Surgery remains an optimal treatment for UCHs located in the ventricular system or originating from the dura mater and an important therapeutic method for UCHs located in the sellar, suprasellar, or parasellar region. Microscopic or endoscopic alternatives and operative approaches must be tailored to the individual lesion characteristics (12,22). Microscopic approaches are suitable in most UCHs, while neuroendoscopy could be considered as an alternative for surgical resection of UCHs located at the lateral ventricles, the third ventricles, or the sellar or parasellar region (12,17,22).…”

“…Microscopic or endoscopic alternatives and operative approaches must be tailored to the individual lesion characteristics (12,22). Microscopic approaches are suitable in most UCHs, while neuroendoscopy could be considered as an alternative for surgical resection of UCHs located at the lateral ventricles, the third ventricles, or the sellar or parasellar region (12,17,22). UCHs originating from the septum pellucidum are very rare, and ventricular vein protection during operation is crucial (Figures 2G, H).…”

Cavernous Malformations: What They Have Taught Us

“…Management of both BSCMs and spinal CMs remains very patient-specific and is largely guided by the neurosurgeon's personal experience and consensus among colleagues. [4][5][6][7][8][9][10] The eagerness to operate on an anxious patient or the personal quest for incremental technical challenge should be tamed by the collective experience of surgical harm. 11 Among the lesions treated in our cerebrovascular discipline, those that require the most abundant surgical acumen, careful patient selection, and personalized longitudinal care are BSCMs and spinal CMs.…”