Left Internal Capsule Cavernoma Using the Superior Frontal Sulcus as a Surgical Corridor: Why and How to Do It: 2-Dimensional Operative Video

Abstract

Cavernous angioma is a sinusoidal dilatation covered by a single layer of endothelium, separated by a collagen matrix with elastin and smooth muscle. 1 The prevalence in the general population is estimated at 0.4% to 0.9%, 2 representing around 5% to 10% of all vascular malformations. 3 Studies indicate 9% to 35% of cavernomas are found in deep locations such as the brainstem, thalamus, and basal ganglia. 4-6 Common symptoms of these deep lesions are cranial nerve deficit, hemiparesis, and paresthesia. These lesions have high rates of rebleeding after the first episode of bleeding but present excellent results of surgical resection and modified Rankin in the long term. 7-13 Internal capsule cavernomas are particularly challenging due to the important projection fibers surround them. Although the gold standard of treatment is microsurgery, there needs to be a consensus on the best approach for lesions of this topography. We present a video case of a female in her 50s with right hemiparesis and dysphasia, exhibiting grade 3/5 strength on the right side. T1 MRI revealed a high intensity, heterogeneous, multinodular signal in the left basal ganglia, with tractography showing the lesion dividing the posterior limb of the internal capsule amid fibers of the right corticospinal tract. The patient consented to the procedure and to the publication of his/her image. This study was approved by the Ethics and Research Committee of our institution. We demonstrated that the superior frontal sulcus is a safe corridor to surgically cure cavernomas of the internal capsule, with the recovery of previous deficits.