PMC9633092_01
Preoperative images. A Computed tomography scan of the high-density area slightly right and lateral to the midline of the midbrain. B FLAIR axial image showing the cavernoma on the right side of the midbrain. C and D The yellow arrows indicate the approach line for the midbrain cavernoma resection. E and F Cerebral angiography showing no abnormal vascularity and suitable bridging veins for the right interhemispheric approach. The yellow arrows indicate the approach line.
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Computed tomography (CT) scans revealed a high-density area slightly lateral to the midline of the midbrain on the right side (Fig. 1A). Magnetic resonance imaging (MRI) revealed a mass lesion with a hemosiderin rim in the same region (Fig. 1B-D). Cerebral angiography revealed no vascular malformations, including venous malformations and bridging veins suitable for the interhemispheric approach (Fig. 1E, F).
Intraoperative findings. A The interhemispheric fissure was divided to expose the corpus callosum between the bilateral pericallosal arteries, and a 10-mm incision in the corpus collosum was made to enter the right ventricle. B The view in the right lateral ventricle where a Monroe foramen, b anterior transparent septal vein, c thalamostriate vein, d choroid plexus, and e internal cerebral vein. C and D The floor of the third ventricle observed from the subchoroidal approach. a Aqueduct. E The vertical incision 2 mm to the right of the midline. F An old fluid hematoma that leaked and was aspirated and decompressed. G and H The main body of CM was identified and grossly removed completely without removing the hemosiderin rim.
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A 10-mm corpus callosum incision was made to enter the right ventricle (Fig. 2A). The Monroe foramen, anterior transparent septal vein, choroid plexus, and thalamostriate vein were identified in the lateral ventricle (Fig. 2B). The third ventricle below the choroidal fissure was then entered to expose the floor of the third ventricle (Fig. 2C, D). Following this, an old fluid hematoma leaked, which was aspirated and decompressed (Fig. 2E, F). The main body of the CM was identified and fully resected without removing the hemosiderin rim (Fig. 2G, H).
Postoperative images. A-C Postoperative DW MRI showing a high-intensity area around the corpus callosum and right anterior thalamus. D-F Postoperative MRI FLAIR showing the same findings as DWI.
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However, MRI, diffusion-weighted image (DWI) and fluid-attenuated inversion recovery (FLAIR) showed high intensity in the corpus callosum and right anterior thalamus (Fig. 3).
Magnetic resonance image 1 month after surgery. A-F DWI and FLAIR showing that the hyperintense lesions in the thalamus and corpus callosum disappeared 1 month postoperatively. G-I T2* and FLAIR showing that the cavernoma was completely removed.
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One month postoperatively, the lesions in the corpus callosum and right thalamus disappeared and were no longer visible on an MRI with the patient's symptoms improving (Fig. 4).