With the further refinement of MRI for neuroimaging, cavernous angioma has become easier to diagnose. Its precise localization can also be assessed with this improved diagnostic modality.
Surgical intervention for cavernous angioma in the pons has been thought to be contraindicated. In recent years, however, reports of surgical treatment for it have increased in number. Some cavernous angiomas in the pons can now be operated on safely by evaluating the precise preoperative localization of the lesion and by using selective intraoperative monitoring.
We report a case of a cavernous angioma in the pons. The patient was operated on using an intraoperative monitoring that could show the location of the facial colliculus. This prevented injury of facial and abducens nerves.
The case was a 5 year-old girl who presented with a right facial palsy 4 days after a blunt injury to her face. An MRI disclosed a small hematoma in the pons of mixed intensity with a perifocal low signal and bulging to the IVth ventricle. Through an osteoplastic suboccipital craniotomy, the floor of the IVth ventricle was exposed. A brownish-discolored bulged region was seen on the right side of the floor with a displacement of the median sulcus to the left. An electromyogram (EMG) of the right M. orbicularis oris was elicited when it was stimulated at the upper half of the bulged region, indicating the right facial colliculus was located beneath the upper part of the bulged area. Through a 4 mm longitudinal incision at the lower half of the bulged area, cavernrus angioma was excised completely.
A conjugate deviation to the left was observed immediately after surgery for a few hours, probably because of transient impairment of the right paramedian pontine reticular formation (PPRF). Palsies of the right facial and the abducens nerves developed postoperatively, but completely resolved in 3 weeks.
The indicaion for cavernous angioma in the pons are when there are signs of a definite hemorrhage, signs of neurological deterioration, and the location is near the pial surface. Total excision must be carried out during surgery to prevent postoperative bleeding.
View full abstract