Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes

Clinical article

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Resection of cavernous malformations (CMs) located in functionally eloquent areas of the supratentorial compartment is controversial. Hemorrhage from untreated lesions can result in devastating neurological injury, but surgery has potentially serious risks. We hypothesized that an organized system of approaches can guide operative planning and lead to acceptable neurological outcomes in surgical patients.


The authors reviewed the presentation, surgery, and outcomes of 79 consecutive patients who underwent microresection of supratentorial CMs in eloquent and deep brain regions (basal ganglia [in 27 patients], sensorimotor cortex [in 23], language cortex [in 3], thalamus [in 6], visual cortex [in 10], and corpus callosum [in 10]). A total of 13 different microsurgical approaches were organized into 4 groups: superficial, lateral transsylvian, medial interhemispheric, and posterior approaches.


The majority of patients (93.7%) were symptomatic. Hemorrhage with resulting focal neurological deficit was the most common presentation in 53 patients (67%). Complete resection, as determined by postoperative MR imaging, was achieved in 76 patients (96.2%). Overall, the functional neurological status of patients improved after microsurgical dissection at the time of discharge from the hospital and at follow-up. At 6 months, 64 patients (81.0%) were improved relative to their preoperative condition and 14 patients (17.7%) were unchanged. Good outcomes (modified Rankin Scale score ≤ 2, living independently) were achieved in 77 patients (97.4%). Multivariate analysis of demographic and surgical factors revealed that preoperative functional status was the only predictor of postoperative modified Rankin Scale score (OR 4.6, p = 0.001). Six patients (7.6%) had transient worsening of neurological examination after surgery, and 1 patient (1.3%) was permanently worse. There was no surgical mortality.


The authors present a system of 13 microsurgical approaches to 6 location targets with 4 general trajectories to facilitate safe access to supratentorial CMs in eloquent brain regions. Favorable neurological outcomes following microsurgical resection justify an aggressive surgical attitude toward these lesions.

Abbreviations used in this paper: CM = cavernous malformation; MCA = middle cerebral artery; mRS = modified Rankin Scale.

Article Information

Address correspondence to: Michael T. Lawton, M.D., Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M780, Box 0112, San Francisco, California 94143-0112. email:

Please include this information when citing this paper: published online July 2, 2010; DOI: 10.3171/2010.5.JNS091159.

© AANS, except where prohibited by US copyright law.



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    Schematic illustration of location and distribution of 79 supratentorial eloquent and deep CMs. Lateral (A), axial (B), and medial (C) views, including sensorimotor (red, in 23 patients [29%]), language (green, in 3 patients [4%]), visual (blue, in 10 patients [13%]), basal ganglia and thalamus (purple, in 27 patients [34%] and 6 patients [8%], respectively), and callosal (orange, in 10 patients [13%]) areas.

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    Surgical approaches to CMs in sensorimotor cortex. M = motor cortex; S = sensory cortex; TC = transcortical approach; TS = transsulcal approach.

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    Transsulcal approach (superficial group). Sagittal FLAIR (A) and axial T2-weighted (B) MR images demonstrating a CM in language cortex (Broca area) with a sulcus leading directly to the lesion (arrow). This sulcus was identified intraoperatively with navigation (C), and the lesion was found at the depths of the sulcus (D). The dissection proceeds around an artery coursing through the sulcus (arrows, E), and the lesion is removed completely (F).

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    Surgical approaches to CMs in language cortex (L). TC = transcortical approach; TS = transsulcal approach.

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    Surgical approaches to CMs in the corpus callosum and cingulate cortex. AIA1 = anterior interhemispheric approach (head turned 90°); AIA2 = anterior interhemispheric approach (head neutral); ATcA = anterior transcallosal approach; PIA = posterior interhemispheric approach; PTcA = posterior transcallosal approach.

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    Surgical approaches to CMs in the basal ganglia. ATiA = anterior transinsular approach; CTcA = contralateral transcallosal approach; PTiA = posterior transinsular approach; SIA = supracarotid-infrafrontal approach.

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    Anterior transinsular approach (lateral transsylvian group). Axial FLAIR (A) and sagittal T1-weighted (B) MR images showing a CM beneath the caudate head and a large associated hematoma. Wide splitting of the sylvian fissure exposes the anterior insular cortex (C). Working through the M2 segments (D) and a thin rim of brain (E), the lesion is removed completely (F). ICA = internal carotid artery.

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    Contralateral transcallosal approach (medial interhemispheric group). Axial FLAIR (A) and coronal T1-weighted (B) MR images showing a small CM in caudate head near the ependymal surface of the right lateral ventricle. The patient's head was turned 90° to the left to allow gravity to retract the left hemisphere and open the interhemispheric fissure (C). An opening in the corpus callosum (CC) exposes the lateral wall of right lateral ventricle. The lesion was identified immediately below the ependymal surface (D), and it was removed completely (E and F). PcaA = pericallosal artery.

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    Posterior transinsular approach (lateral transsylvian group). Axial FLAIR (A) and sagittal T1-weighted (B) MR images showing a CM in the dominant hemisphere behind the posterior limb of the internal capsule. Distal splitting of the sylvian fissure exposed the posterior insula (C and D). The lesion was found beneath the cortical surface and was removed completely (E), carefully preserving the superficial and deep middle cerebral veins (F).

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    The supracarotid-infrafrontal approach (lateral transsylvian group). Axial T2-weighted (A) and sagittal T1-weighted (B) MR images showing a CM in the anteroinferior basal ganglia. After splitting the sylvian fissure, the internal carotid artery bifurcation, M1 segment, and A1 segment (ACA) are seen forming the vascular borders of the supracarotid triangle (C). With some retraction on the posterior aspect of the medial orbital gyrus, the supracarotid triangle is widened to expose lenticulostriate arteries coursing to the anterior perforated substance. A small cortical incision in medial orbital gyrus accessed the CM (D), which was removed completely (E). The resection was completed by working between ascending lenticulostriate arteries and a deep frontal venous anomaly in the wall of the transfrontal corridor (arrow, F).

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    Surgical approaches to CMs in the thalamus. ATcTchA = anterior transcallosal transchoroidal approach; PTiA = posterior transinsular approach; PTcA = posterior transcallosal approach; and ScItA = supracerebellar-infratentorial approach.

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    Transcallosal-transchoroidal approach (medial interhemispheric group). A: Axial T2-weighted MR image demonstrates a CM in the medial thalamus, abutting the third ventricle. B: A contralateral transcallosal approach exposed the pericallosal arteries (PcaA) and corpus callosum (CC). C: The right lateral ventricle was entered through corpus callosum, exposing the choroid plexus (CP) and thalamostriate vein (TSV). D: The choroidal fissure was opened to enlarge the Monro foramen and enter the third ventricle. E and F: The CM (arrows) was seen after dividing massa intermedia (MI; E) and (F) removed completely (F).

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    Paramedian supracerebellar-infratentorial approach (posterior group). Axial T2-weighted (A) and sagittal T1-weighted (B) MR images showing a CM in thalamus with an associated hematoma that reaches the pulvinar surface. Intraoperative photographs showing the exposure through a torcular craniotomy (sitting position) and to the right of central lobule (CL) of a descended cerebellum (C). Hemosiderin staining is seen on pulvinar of thalamus, above superior colliculus (SC) of quadrigeminal plate and lateral to the pineal gland. Note the loop of posterior cerebral artery (PCA) dropping below tentorium (Tent). After evacuating the hematoma, a thalamic CM was encountered at the depths of the cavity (D) and removed completely (E). The operative corridor is below the Galenic venous complex (basal vein of Rosenthal [BVR] and precentral cerebellar vein [PCV]), and it is opened naturally by gravity retraction (F).

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    Surgical approaches to CMs in the visual cortex. PIA = posterior interhemispheric approach; StIoA = supratentorial-infraoccipital approach; TC = transcortical approach; TS = transsulcal approach.

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    Supratentorial-infraoccipital approach (posterior group). Axial T2-weighted (A) and coronal FLAIR (B) MR images showing a CM in the medial occipital lobe, adjacent to the posterolateral midbrain. The lesion reaches the cortical surface along the inferior occipital lobe along tentorium (Tent; C). The approach minimizes transgression of visual cortex (D), and the lesion is removed completely (E). The lateral ventricle is entered at the anterior aspect of the resection cavity (F).

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    Neurological outcomes after microsurgical resection of eloquent CMs.



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