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Presigmoid approach preserving the superior petrosal sinus in a pontine cavernous malformation associated to abnormal venous drainage of the brainstem: how I do it

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

The presigmoid approach classically includes the ligature and section of the superior petrosal sinus to get a wider visibility window to the antero-lateral brainstem surface. In some cases, the separation of this venous structure should not be performed.

Method

We present our experience getting safely to a pontine cavernous malformation through a conventional mastoidectomy presigmoid approach preserving an ingurgitated superior petrosal sinus because the association with an abnormal venous drainage of the brainstem.

Conclusions

When sectioning the superior petrosal sinus in classical presigmoid approaches is contraindicated, its preservation could also offer good surgical corridors to get to small-medium anterior and lateral brainstem cavernous malformations.

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Abbreviations

SPS:

Superior petrosal sinus

AVD:

Abnormal venous drainage

CN:

Cranial nerves

TS:

Transverse sinus

SS:

Sigmoid sinus

SCC:

Semicircular canals

LSCC:

Lateral semicircular canal

PSCC:

Posterior semicircular canal

TT:

Trautmann triangle

References

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Acknowledgements

We would like to thank to Dr. Maria J Mayorga, our pediatric anesthesiologist for all the support, to Dr. Ariel Kaen and Dr. Eugenio Cárdenas, including the rest of our Neurological Surgery department at Virgen del Rocío University Hospital, for all the usual support in research and investigation.

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Authors and Affiliations

  1. Department of Pediatric Neurosurgery, Virgen del Rocío University Hospital, Av. Manuel Siurot, 41013, Seville, S/N, Spain

    Carlos Butrón-Díaz, Cristina Romero-López, Mónica Rivero-Garvia & Javier Márquez-Rivas

  2. Group of Applied Neuroscience, Biomedicine Institute of Seville, Seville, Spain

    Carlos Butrón-Díaz, Cristina Romero-López, Mónica Rivero-Garvia & Javier Márquez-Rivas

  3. Department of Neurological Surgery, Virgen del Rocío University Hospital, Av. Manuel Siurot S/N, 41013, Seville, Spain

    Carlos Butrón-Díaz

Authors
  1. Carlos Butrón-Díaz
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  2. Cristina Romero-López
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  3. Mónica Rivero-Garvia
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  4. Javier Márquez-Rivas
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Corresponding author

Correspondence to Carlos Butrón-Díaz.

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Key points

Preoperative study by contrast MRI and tractography. Evaluation of compromised neurovascular structures, major neuronal pathways and AVDs presence even with angiography, is crucial.

Preservation of superior petrosal sinus! When indicated, this is a good and acceptable limited way to get to small and medium anterior and lateral brainstem lesions.

Prevent extensive venous infarctions. Preservation of AVDs is important to minimize risk and comorbidities.

Precaution! When IONM alerts of neurological impairment during surgery, remember resting, irrigation, and corticoids bolus rescue doses.

Bony structures and venous sinuses variation assessment. It is mandatory to evaluate and predict possible problems with the Trautmann triangle delimitation and aeration of mastoid.

Check and preserve the semicircular posterior and lateral canals. They will be our anterior TT limits for drilling.

Get indocyanine green. When dealing with non-exophytic lesions, intraoperative fluorescein could be helpful to select the better and safer point to enter the brainstem.

Neurological surveillance. Intraoperative neurophysiological monitoring (INMO) is always suitable in this type of surgeries.

Add corticosteroids postoperatively. Short therapies are related to neurological improvement after surgery.

Evaluate the indication of surgery. Neurological impairment and rebleeding are the first conditions to indicate surgical treatment.

This article is part of the Topical Collection on Neurosurgical technique evaluation

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Butrón-Díaz, C., Romero-López, C., Rivero-Garvia, M. et al. Presigmoid approach preserving the superior petrosal sinus in a pontine cavernous malformation associated to abnormal venous drainage of the brainstem: how I do it. Acta Neurochir 165, 1233–1240 (2023). https://doi.org/10.1007/s00701-022-05407-3

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  • DOI: https://doi.org/10.1007/s00701-022-05407-3

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