Giant pediatric brainstem cavernoma: illustrative case

Abstract

Background: Cerebral cavernous malformations are low-flow vascular lesions and the most common of all vascular pathologies encountered by neurosurgeons. The location of these lesions is critically important in determining the symptomatology and whether intervention is indicated. Cavernous malformations localized to the brainstem are often the most complex of these to manage given the density of critical structures and tracts found within the brainstem.

Observations: Here, the authors present the case of a 3-year-old male who presented with hemiparesis and eventually developed hydrocephalus from a giant brainstem cavernous malformation. The patient initially did well on steroids but had a recurrent hemorrhage that led to worsening hemiparesis and hydrocephalus. The authors then elected to resect the cavernous malformation via a supracerebellar infratentorial approach utilizing intraoperative MRI to ensure complete resection. Postoperatively, the patient returned to near baseline neurological function.

Lessons: The authors describe an uncommon approach to the management of a pediatric patient with a giant brainstem cavernous malformation by carefully examining the potential approaches and utilizing available technologies to ensure an excellent outcome for the patient. https://thejns.org/doi/10.3171/CASE24814.

Keywords: brainstem cavernoma; brainstem cavernous malformation; pediatric cavernoma; supracerebellar infratentorial approach.

FIG. 1.

A–C: Initial axial (A), coronal (B), and sagittal (C) CT scans demonstrating a right-sided mixed density mass within the posterior fossa. D–F: Axial (D), coronal (E), and sagittal (F) T2-weighted MR images demonstrating a cystic T2 hyperintense and hypointense lesion within the right-sided pons, concerning for potential cavernous malformation measuring 3.3 × 3.2 × 3.0 cm. G–I: Subsequent interval axial (G), coronal (H), and sagittal (I) T2-weighted images demonstrating an interval increase in the size of the pontine cavernous malformation with an additional hemorrhage, now measuring 4.0 × 3.9 × 2.9 cm, as well as interval enlargement of the supratentorial ventricular system.

FIG. 2.

A–C: Intraoperative axial (A), coronal (B), and sagittal (C) T2-weighted MR images demonstrating gross-total resection of the pontine cavernous malformation. D–F: Three-month postoperative axial (D), coronal (E), and sagittal (F) T2-weighted images demonstrating continued gross-total resection of the cavernous malformation with expected hemosiderin staining and a decompressed supratentorial ventricular system.