Removal of Cavernomas

With cavernomas, coagulation of the lesion will shrink it to such a degree that feeding vessels become identifiable, which then can be closed and transected. The hemosiderin-stained glial tissue around a caver-noma should not be removed. It is the result of repeated minor hemorrhages, does not belong to the pathology, and helps to preserve the surrounding cord tissue as a good protective layer (Fig. 3.52) [34, 216, 246]. Furthermore, some cavernomas are accompanied by large veins, so called developmental venous anomalies (DVAs). These veins have to be preserved as they drain normal tissue and do not represent tumor vessels [293]. However, it appears that DVAs are not a common feature of spinal cavernomas compared to other central nervous system locations.

Fig. 3.52. (Continued) T1-weighted, contrast-enhanced sagittal MRI images (a), and sagittal (b) and axial (c) T2-weighted MRI images of an intramedullary cavernoma at C2/3 on the right side in a 51-year-old woman with occipital pain on the right side. d This intraoperative picture after dura and arachnoid opening, taken with the patient in the semisitting position, shows a completely normal cord surface. e With opening of the pia at the dorsal root entry zone with two microdissec-tors, the gliotic tissue and remnants of small hemorrhages are visible. f With bipolar coagulation and application of suction on a very low setting, the cavernoma became visible, shrank, and disclosed the dissection plane. g After removal of the cavernoma, some of the surrounding gliosis is visible in the upper half (arrowhead). After releasing the pia retention sutures (h) the cord was closed with a 8-0 pia sutures (i). The postoperative, contrast-enhanced T1-weighted image (j) and the T2-weighted sagittal (k) and axial (l) scans after 1 year reveal a complete resection. The patient had no postoperative neurological deficits and reported a marked relief of pain

Fig. 3.52. (Continued) T1-weighted, contrast-enhanced sagittal MRI images (a), and sagittal (b) and axial (c) T2-weighted MRI images of an intramedullary cavernoma at C2/3 on the right side in a 51-year-old woman with occipital pain on the right side. d This intraoperative picture after dura and arachnoid opening, taken with the patient in the semisitting position, shows a completely normal cord surface. e With opening of the pia at the dorsal root entry zone with two microdissec-tors, the gliotic tissue and remnants of small hemorrhages are visible. f With bipolar coagulation and application of suction on a very low setting, the cavernoma became visible, shrank, and disclosed the dissection plane. g After removal of the cavernoma, some of the surrounding gliosis is visible in the upper half (arrowhead). After releasing the pia retention sutures (h) the cord was closed with a 8-0 pia sutures (i). The postoperative, contrast-enhanced T1-weighted image (j) and the T2-weighted sagittal (k) and axial (l) scans after 1 year reveal a complete resection. The patient had no postoperative neurological deficits and reported a marked relief of pain

With anteriorly located cavernomas, several surgical options can be used. With sutures applied to dentate ligaments, the spinal cord may be rotated so that the anterolateral section of the cord becomes accessible even from a posterior approach. With resection of facet joints and pedicles, an even better access is achieved with this technique [208]. Another alternative is a ventral approach with partial or complete corpectomy and stabilization [97, 292].

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