Combined petrosal approach for resection of recurrent brainstem cavernous malformation: operative video and technical nuances

Brainstem cavernous malformations are formidable lesions because of their eloquent location and propensity for bleeding resulting in neurological impairment. The surgical management can be challenging due to their deep location around critical neurovascular structures. In this operative video manuscript, the authors demonstrate resection of a large recurrent pontine cavernous malformation with an exophytic component in the cerebellopontine angle via a combined petrosal approach. Both anterior and posterior (retrolabyrinthine) petrosectomies were performed to allow multi-corridor access to the lesion. Due to excessive scar formation from prior surgeries, sharp dissection was paramount to create dissection planes around the lesion. This video atlas demonstrates the operative technique and surgical nuances of the skull base approach, safe resection of the malformation through the operative corridor, gentle handling of the neurovascular structures and a multi-layered reconstruction technique to prevent cerebrospinal fluid leakage. The use of endoscopic-assisted microsurgery of the brainstem is also demonstrated. A gross total resection was achieved, and the patient improved neurologically. In summary, the combined petrosal approach with endoscopic assistance is an important strategy in the armamentarium for the surgical management of brainstem cavernous malformations. The video can be found here: https://youtu.be/oAETW6tVc_Y.