Cavernous malformations of the midbrain require careful consideration of the risks and benefits of intervention, as well as optimal surgical approach for these challenging lesions. Excellent results can be achieved with careful surgical planning and technique.1,2 In this operative video, we demonstrate a contralateral left pterional craniotomy for trans-lamina terminalis approach to CO2 laser-assisted microsurgical resection of a thalamo-mesencephalic cavernoma in a 59 year old female presenting with progressive debilitating diplopia secondary to partial third nerve palsy. We utilized a contralateral left modified pterional craniotomy in which we limit dissection of the temporalis muscle to approximately one third rather than extending the muscle split down to the zygoma. The cavernous malformation was resected without complication and the patient was discharged from hospital on post-operative Day 3. She noted immediate improvement and nearly complete resolution of her symptoms over ensuing weeks. This approach offers a direct route to the lesion with minimal brain transgression while avoiding the critical structures within the interpeduncular cistern including basilar artery and thalamo-mesencephalic perforating arteries, as well as bordering neural structures including cerebral peduncles, oculomotor nerves and mamillary bodies. Use of the CO2 laser, with its 0.55mm tip, offers a low surgical profile and allows for precise cutting thus minimizing thermal damage to surrounding tissues. The trans-lamina terminalis approach, through a pterional craniotomy, offers a safe and potentially less morbid alternative to select thalamo-mesencephalic lesions compared to exposure through the mesencephalic surface which in our experience often necessitates an orbitozygomatic craniotomy.
View details for DOI 10.1016/j.wneu.2020.04.115
View details for PubMedID 32360676