• History & Physical: The patient is a 44 year-old right handed male with a 3 month history of progressive left facial parasthesias, numbness, diploplia, vertigo, nausea and emesis. His vertigo has progressed to the point were he is now bed ridden. He has lost 50 lbs since the onset of his symptoms secondary to severe nausea.

    On exam, his pupils are equal and reactive. Extra-ocular movements are grossly intact, however he does demonstrate horizontal and rotatory nystagmus on lateral gaze. The corneal reflex is absent on the left. There is decreased facial sensation to light touch and pin-prick in the left V1 and V2 distributions. The ag reflex is diminished on the left. Upper and lower extremity strength is intact, grade 5/5. The left upper extremity is dysmetric to finger to nose testing.

    Figure 1-4. (Below) Sagittal T1-weighted MRI revealed a hemorrhagic left pontine lesion at the level of CN V extending dorsally to the floor of the 4th ventricle consistent with a cavernoma.

    This patient was offered surgery due to his progressive and incapacitating symptoms. His operation was a planned, two-stage procedure. The first stage was a left retrosigmoid suboccipital approach to remove the cavernoma at the level of V that was bulging into the CPA. He was then brought back to the OR 7 days later for a midline sub-occipital approach through the floor of the 4th ventricle. The patient did well with only residual intermittent nausea and has returned to work 8 weeks post-op. Post-operative imaging shows complete resection of the cavernomas. (Figure 5 Below) Pathology was consistent with cavernoma. 

    Figure 1A.

    Figure 1B.

    Figure 2. Coronal T1

    Figure 3. Axial T1

    Figure 4. Axial T2

    Figure 5. Post-op T2

    1. Does this patient need any further work-up?

    2. Is an angiogram indicated?

    3. How would you manage this patient?

    4. If you were to manage this patient expectantly, how would you follow him?

    5. If you were to offer this patient surgery, what approach would you use?

    6. If you were to use a combined approach (e.g. midline sub-occipital and retrosigmoid suboccipital) would you do it at one sitting or staged?

    7. Please add any suggestions or comments regarding this case:

    We have had the same experience with one of our patients with good results. In our opinion progressive and incapacitating symptoms represent a true indication to surgical treatment, without any delay.

    Taking in to account the "two point rule" to approach any lession inside the neuraxis, a presigmoid approach would be a reasonable technique in this patient. With this technique one sitting would have being enough to remove the lession. However, the used approach is a ggod one, so I congratulate the surgeons for their choice.

    Nice Job. Remarkably

    great case

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