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Amets Sagarribay1, Miguel Correia1, Mário Matos1, António Baptista1, Carla Conceição2.

1 - Neurosurgical Pediatric Unit, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE;
2 - Pediatric Neuroradiology Unit, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE.

 - 23rd ESPN Congress Session 3: "Miscellaneous", University of Amsterdam, May 1 (Apresentação).

Objective: Cavernous malformations in the antero-inferior basal ganglia and hypothalamus are very rare and of difficult surgical management due to their relationship with basal ganglia, anterior perforated substance, hypothalamus and internal capsule. Although sometimes considered inoperable, many approaches have been proposed to reach this area: transcallosal, transcortical, transsylvian-transinsular and trough the supracarotid triangle. The authors describe an alternative approach with a supraorbital craniotomy, subfrontal route and a infracarotid infrafrontal microsurgical and endoscopically assisted approach.

Methods: The infracarotid infrafrontal endoscopicaly assisted approach incorporate a supraorbital craniotomy by na eyebrow incision (not included the orbital rim) , a subfrontal route to the basal cisterns, wide exposure of the supracarotid triangle and the triangle between optic nerve-optic tract, ACI and ACA-A1 segment (the opto-carotid triangle). These working channels may enable the surgeon to ressect completely cavernomas located in the hipothalamus and antero-inferior basal ganglia working medially and inferiorly to the supracarotid triangle, avoiding cortical incision in the medial orbital gyrus or working between perforators and with the help of the endoscope coming into view the blind gap at the upper part of the lesion during ressection. The authors describe this technique used in a 15 years old patient with a right antero-inferior basal ganglia/hypothalamus cavernoma and we review literature in Pubmed/MEDLINE database.

Results: The authors report the case of a 15 years old boy, with a known right subpalidal/hypothalamic cavernoma treated conservatively because it had never bleed before, until he had a sudden headache and homonymous cuadrantanopsy. The CT scan showed a hematoma in the right basal ganglia and hypothalamus without intraventricular or cisternal extension. We approached the lesion by a right supraorbital craniotomy, an infracarotid infrafrontal microsurgical and endoscopically assited approach and ressected completely the cavernoma and the associated hematoma. He had an uneventful postoperative period. We also compare video images from the microscope and from a 0º and 30º degrees rigid endoscope to show the beneficts of using both tools.

Conclusions: The infracarotid infrafrontal endoscopically assisted approach is a safety approach to treat cavernomas located in the antero-inferior basal ganglia and hypothalamus. It is a direct approach to the supracarotid and opto-carotid triangles and avoids cortical incision in the medial orbital gyrus, working between perforators and splitting the sylvian fissure. The use of the endoscope increase our capability to visualize the upper part of the lesion that can not be seen under the microscope making surgery more safe and reducing risks of damaging basal ganglia, hypothalamus and internal capsule.

Palavras-chave: Cavernous malformations.