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1/32. Experience in surgical management of tumours involving the cavernous sinus.

    Potential injury to the neurovascular structures within the cavernous sinus often prohibits aggressive removal of tumours involving it, however, fully understanding the anatomy and selecting an appropriate surgical approach can often resolve this problem with acceptable morbidity. Moreover, a tumour may originate from different anatomical structures of the cavernous sinus which will influence the difficulty and outcome of the surgery. In general, tumours in this region can be classified as intradural, intracavernous and invasive types. The strategy of surgical treatment varies among these different anatomical types. Therefore, preoperative evaluation of tumours in the cavernous sinus is critical for the selection of an appropriate microsurgical approach. During the past 5 years, 12 tumours involving the cavernous sinus have been operated upon which included four neuromas, three meningiomas, three cavernous haemangiomas, one plasmacytoma and one chondroma. Nine of these twelve tumours were totally resected after one or two operations. There was no surgical mortality and the most common morbidity was transient cranial nerve palsy. At 2 months after surgery there was no additional postoperative cranial nerve deficit in all the patients; however, one patient developed a postoperative middle cerebral artery infarct due to accidental injury to the internal carotid artery during surgery. The respectability of the tumour mostly depends on its consistency and the involvement of the adjacent anatomy. The pathoanatomical features of the tumours and the clinicoradiological findings, as well as the selection of the microsurgical approach, are discussed.
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2/32. Rapid growth in a cavernoma.

    The availability of magnetic resonance imaging has greatly increased the detection of cavernous malformations of the central nervous system in both symptomatic and asymptomatic patients. These lesions may be responsible for previously unexplained neurological events or may even have been incorrectly diagnosed. We describe a patient presenting with focal neurological signs in whom an initial diagnosis of malignant glioma had been made. Following excision, the pathological diagnosis was cavernoma. This vascular lesion has continued to show rapid growth and aggressive behaviour despite multiple surgical resections. The indications for operative and non-operative intervention will be discussed.
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3/32. Cavernous haemangioma in the cavernous sinus: case report and review of the literature.

    We report a cavernous haemangioma in the left cavernous sinus. This lesions very rarely occurs in this site and is difficult to diagnose correctly preoperatively. CT, angiography and MRI permit differentiation of the cavernous haemangioma from other tumours in this region and thereby contribute to a better surgical approach. The radiological features of cavernous haemangioma reported in the literature are summarised.
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4/32. Surgery of a cavernous angioma making a tunnel between the fourth ventricle and tubercle.

    We removed a cavernous angioma, making a tunnel between the fourth ventricle and tubercle using the traction-dissection method. Cavernous angioma with such a distribution is extremely rare, and we manipulated the mass differently to minimize surgical damage. Intraoperative findings and technical considerations are made.
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5/32. Minimally invasive treatment of cavernous angioma of the optic chiasm: case report.

    Cavernous angioma of the optic chiasm or optic nerve is extremely rare. We report the case of a 58-year-old woman with cavernous angioma of the optic chiasm. The lesion was totally removed through the eyebrow keyhole approach, which allowed appropriate intraoperative exploration of the optic chiasm and related structures. The present case confirms that a cavernous angioma located in the optic chiasm can be totally resected without further impairment of visual function.
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6/32. Intramedullary cavernous angiomas of the spinal cord in the pediatric age group: a pediatric series.

    The authors have reviewed available data from 7 pediatric patients with intramedullary spinal cord cavernous angioma (ISCCA) reported in the literature, and added from their own series 2 pediatric patients, for a total of 9 patients. This group of pediatric patients' clinical presentation, course, management and outcome were compared to their adult counterparts as reported in the literature. In contrast to adults, children with symptomatic ISCCA do not show a gender imbalance and the thoracic spinal cord is not predominantly involved. Pediatric patients commonly present with an acute episode and rapid deterioration. A more favorable outcome has been reported in children as compared to adults in the face of relatively similar presenting deficits. As in adults, magnetic resonance imaging (MRI) remains the diagnostic and postoperative test of choice. Complete resection affords the best chance for cure. Symptomatic children with ISCCA characteristically present with an acute deficit and rapid deterioration. MRI of the entire neuraxis is recommended for lesion multiplicity. An attempt at total resection and long-term MRI follow-up are recommended.
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7/32. Endoscopic fenestration of symptomatic septum pellucidum cysts: three case reports with discussion on the approaches and technique.

    OBJECTIVES: We describe three patients with symptomatic septum pellucidum cysts treated by endoscopic fenestration and discuss the different endoscopic approaches to these cysts. CLINICAL PRESENTATION: The patients are an 8-year-old boy, a 7-year-old boy and a 21-year-old woman; this last also had a right frontal cavernous angioma and a pituitary microadenoma. All patients presented with headache, associated with vomiting in two and behavioral changes in one. In all cases magnetic resonance showed a septum pellucidum cyst. INTERVENTION: Two patients were operated upon by posterior approach through a right occipital burr hole and underwent fenestration from the right occipital horn to the cyst, with a second fenestration from the cyst to the left lateral ventricle in one. Another patient underwent microsurgical removal of a right frontal cavernoma and endoscopic cyst fenestration with both lateral ventricles through a right frontal craniotomy. Postoperatively, headache and vomiting resolved in all cases and behaviour changes improved in one. CONCLUSIONS: Endoscopic fenestration is the treatment of choice for septum pellucidum cysts, where it results in immediate relief of the mass effect of the cyst and in the remission of the associated symptoms. We suggest a posterior approach through a right occipital burr hole. It allows one to easily cannulate the occipital horn, which is usually larger than the frontal one, thus avoiding the risk of damaging the vascular and neural structures surrounding the foramen of Monro. Besides, the endoscopic trajectory is in our opinion more direct. The two-window technique, with fenestration of the cyst into both lateral ventricles, improves the chances of long-term patency.
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8/32. Transposition of the oculomotor nerve for resection of a midbrain cavernoma. Technical note.

    The authors discuss the utility of anterior transposition of the oculomotor nerve from the lateral wall of the cavernous sinus to widen the corridor posterior to the cisternal segment of the oculomotor nerve; this allows exposure of the anterolateral surface of the midbrain. This additional exposure was successfully used for the resection of a large calcified cavernoma in the upper brainstem of a 67-year-old woman who had presented with sudden onset of left hemiparesis and oculomotor palsy. The patient's postoperative course was uneventful and she displayed symptomatic improvement.
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9/32. Preoperative evaluation of neural tracts by use of three-dimensional anisotropy contrast imaging in a patient with brainstem cavernous angioma: technical case report.

    OBJECTIVE AND IMPORTANCE: We describe a case of brainstem cavernous angioma in which the neural tracts were evaluated before surgery by three-dimensional anisotropy contrast (3-DAC) magnetic resonance imaging. CLINICAL PRESENTATION: A 64-year-old man presented with a cavernous angioma located intrinsically in the brainstem and manifesting as gait ataxia. 3-DAC imaging demonstrated that the lesion was located outside the left inferior cerebellar peduncle and inside the middle cerebellar peduncle. INTERVENTION: The intact brain surface was incised, and the lesion was removed successfully on the basis of the preoperative 3-DAC images. The patient exhibited temporary exacerbation of his gait ataxia, but the symptom improved 3 months after surgery. Postoperative 3-DAC imaging demonstrated resection of the lesion and preservation of the left inferior and middle cerebellar peduncles. CONCLUSION: 3-DAC imaging may provide essential information about the neural tracts for the planning of brainstem surgery.
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10/32. Recurrent cryptic vascular malformation associated with a developmental venous anomaly.

    Abnormal venous drainage patterns, such as developmental venous anomalies (DVAs), are frequent findings neighbouring cryptic vascular malformations (CVMs). Although the clinical relevance of DVAs remains controversial, increasing attention has been focused on the possible importance of venous outflow disturbance and venous hypertension in DVAs for the development of CVMs. We present the case of a 32-year-old man with dysphasic seizures symptomatic for recurrence and rebleeding of a CVM of the left angulare gyrus, which drained entirely into a large DVA. A cavernoma had been surgically removed 1 year before, while the associated DVA had been left in place. In the following second surgical procedure, the new malformation, which was histologically verified as arteriovenous angioma (AVM), was removed and the DVA was occluded for the length of the angioma. Postoperative course of the patient was unremarkable, the patient is seizure free and neurologically intact. This first report of such a sequence of events raises important questions regarding the association of various vascular malformations, regarding transitional and hybrid forms, as well as the role of anomalous venous drainage in their pathophysiology and probably in their development. Our case and selected cases in literature suggest that venous hypertension in a DVA might not be just a coincidential finding, but sometimes can induce or influence the development and recurrence of associated vascular lesions. The developmental interrelationship, the potential mechanisms for this association and the implications of similar cases reported in pertinent literature are discussed.
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keywords = operative
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