• H&P

    • 49 year-old woman with balance difficulty, vertigo, and blurry vision
    • PMH: HTN, anemia
    • Meds: amlodipine, lisinopril, dyazidea
    • Exam: neuro intact except for difficulty with heel to toe test bilaterally

    Figure 1

    1. The treatment for this patient would be:
    2. If performing surgical resection, would you use:
    3. Cavernous Malformations have been associated with genetic mutations in:
    4. Risk of hemorrage from this lesion:
    5. Which of the following best describes you?
    6. I practice in one of the following locations.
    7. Please add any suggestions or comments regarding this case:
    • In this case she has neurological deficits, with a lesion causing mass effect. Although many times we would wait for an event to occur (bleed) in this case it could be devastating and resecting the lesion early rather than late, with intraoperative neuromonitoring may be ideal.
    • The risks of surgery here are formidable, with no really good approach surgically in a virtually intact patient. The natural history of a lesion presenting like this patient's is totally unknown --despite what the papers say -- and the patient's clinical course should dictate treatment. A rehemorrhage would encourage an operative approach were the deficits significant enough and if the lesion breeched the pia somewhere. Surgery through the IVth ventricle in this situation is rarely without permanent sequaelae.
    • The use of fourth ventricular surface mapping & cranial nerve monitoring may be of value
    • I would like to suggest perillyl alcohol inhalation.
    • As a medical student, I believe the patient is suffering from Schwanoma, often localized to cranial nerve 8, which is the third most common primary brain tumor. This tumor is located at the Cerebellopontine angle hence affecting the patient balance, vertigo. The best approach is surgical resection via the retrosigmoid approach (which is commonly used for these type of tumors-CN8 Schwanomas). You could also use stereotactic surgery However stereotactic navigation and intraoperative MRI would be the best approach when deciding to resect. Common mutations are in CCM2, KRIT1, PDCD10.
    • It was gud
    • I would use intraoperative neurophysiology monitoring
    • Excellent case
    • Does not seem to come to the surface and the patient has suffered minimal morbidity that may improve with time. Surgery will likely set this person back, potentially permanently. I'd await at least another true hemorrhagic event.
    • Tough case
    • There is no one best treatment strategy in such a case. I think however that surgery gives the best perspective for the patient. In my opinion both approaches (retrosigmoid and via 4th ventricle) are acceptable, however I prefer the telovelar approach.
    • DTI for assessing white matter tract surrounding the lesions would be an essential part of my preoperative planning.
    • Thank you for keeping this up.
    • Bleed risk is 0.7-1.7%/yr/lesion, with this range not a possible multiple choice answer.
    • great case
    • I would use IV ventricle floor mapping.
    • More open ended options in the surgical side are required. For eg: a combined anterior approach may be prefered by some which is not listed. USG is not listed in the intraop adjuncts which is as good as the other modalities when used properly.
    • Could be a observation management but in that location is a good alternative surgical management by retrosigmoid approach
    • In my opinion it is a cavernoma.It can be excised under sterotactic navigation and intraoperative mri.
    • The patient is almost no symptomatic and is in the most active time of her life. So I would not consider the functioonal risks that undoubtely surgery carries on to be justified by the clinical situation. As any symptom would worsen, surgey would be indicated. The use of DTI technology would possibly help in selecting the most appropriate approach, whether via a IV ventricle or via a lateral pontine incision following a Kawase's approach.
    • I like discussing cases,which improves knowledge and helpful to teach residents.
    • IN case of bleeding and subsequent need for surgery, I would opt for petrosal presigmoid approach
    • IN case of bleeding and subsequent need for surgery, I would opt for petrosal presigmoid approach
    • We had a similar case, a 32 yr old male. The cavernoma was fust touching the pial surface. So we proceeded to resect the tumor after explaining all risks. The patient came out well, but on 2 nd POD he went in for sudden arrest and could not be resuscitated.
    • If she worsened clinically or bled again, I would approach transpetrosal presigmoid.
    • Upon worsening of symptoms, I would recommend surgery with a left-sided lateral approach to the brainstem (presigmoid and retrolabyrinthine approach)
    • Approaching brain stem cavernous lesions should be done through the approach that provides minimal pial breach and also avoiding the posterior and posterolateral approaches to the brain stem where the nuclei and vital centers are crowded. This entails, anterior and antero-lateral approaches that may go through tracts and fibres mainly
    • This lesion may be a brain stem cavernoma


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