Commentary: Microsurgical Resection of a Medulla Oblongata Cavernoma: 3-Dimensional Operative Video

Abstract

T his video article 1 reports a case of 53-year-old female patient presenting with headache, dysphagia, and quadriparesis of 2-year duration. Magnetic resonance imaging revealed cavernoma located in upper portion of medulla oblongata with evidence of bleeding. The authors decided to proceed into surgical resection, to avoid the risk of any future devastating hemorrhagic events or neurological deficits because of brainstem compression.The patient was operated in the semisitting position using the transtonsillar medial suboccipital approach. Microsurgical complete resection of the lesion was performed under neurophysiological monitoring. The patient recovered without any new neurological deficits, and she restored her neurological functions gradually and completely within 6 months postoperatively after a course of rehabilitation.Cavernomas or cavernous malformations are vascular lesions, and when occurring in the brain, they are associated with high risk of hemorrhage and seizures. The incidence of cavernomas occurring in central nervous system ranges between 0.4% and 0.9%. 2 These lesions usually occur in supratentorial region; about 20% are located in the brainstem. 3 Approximately 15%-30% of brainstem cavernomas are located in the medulla oblongata. 4 The medulla oblongata is a small neurological zone in brainstem with extremely important vital structures, mainly respiratory, cardiac, vomiting, and vasomotor centers regulating involuntary and autonomic functions such as heart rate, respiration, and blood pressure. It also contains corticospinal tracts, ascending sensory tracts, and nuclei of lower cranial nerves. 5 Surgical removal of these lesions is more challenging than other sites of the brainstem because of complex anatomic structure of the medulla oblongata and the presence of vital neural nuclei and fibers which regulate normal body circulation and respiration. 4 Accordingly, any slight injury to the medulla oblongata due to intraoperative manipulations might result in significant neurological deficits.Surgical interference is indicated for patients who are subjected to single or repeated symptomatic hemorrhagic attacks with progressive/persistent neurological deficits and in patients with