Recurrent Hemorrhagic Central Pontine Cavernoma Resection by Retro Sigmoid Microsurgical Approach
Kamalpreet Mann1, Emili Mondragon1, Bobbi Thursam1, Muhammad Farooq2, Bradley Haveman-Gould3
1Trinity Health Grand Rapids, 2Neuroscience Program,Saint Mary'S Health, 3Trinity Health Physician Partners
Objective:

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Background:

Pontine cavernomas carry a surgical risk due to their eloquent location in the brainstem. Resection of pontine cavernomas carries risk of mortality and morbidity based on factors including characteristics of the lesion and surgical technique used. Typically, microsurgical resection is pursued if the cavernoma has an exophytic component. We present a case of recurrent hemorrhage of central pontine cavernoma with successful resection by retrosigmoid approach. 

Design/Methods:
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Results:

52-year-old male with history of tobacco use presented to hospital with one month of fluctuating symptoms of left hemiparesis and hemianesthesia. Initial MRI brain showed oval 2.1x2.1 cm central brainstem cavernoma with hemorrhage. Neurosurgery recommended close follow-up MRI brain.  

He was readmitted one month later for worsening symptoms. Repeat MRI brain revealed increased size of hemorrhagic cavernoma to 2.6x2.2x2.4cm with edema and partial effacement of 4th ventricle. Neurosurgery performed an evacuation of the hemorrhage and the central pontine cavernoma with retrosigmoid approach. Pre-surgery patient was noted to have impaired horizontal movements of the right eye, left hemianesthesia, dysarthria, and left arm weakness. Post-surgery he had the same pre-surgical deficits and impaired adduction of the left eye.  

Postoperative day 2, repeat CTH revealed re-accumulation of hematoma in the central pons. He was given tranexamic acid. The patient underwent a second surgery for resection of the hematoma. After this surgery, the patient had improvement in left hemiparesis and ocular movements of the left eye. The patient was discharged to acute rehab.  

Conclusions:
Resection of a brainstem lesion is a high-risk procedure. Mortality rates for pontine surgery can range from 1 to 10 %. However, more recent studies show decreased mortality due to advancements in surgical techniques. This case shows a successful excision of recurrent hemorrhagic central pontine cavernoma, without exophytic component, using a microsurgical retrosigmoid approach for resection – allowing maximal preservation of surrounding eloquent tissue.  
10.1212/WNL.0000000000211197
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