Third Ventricular Cavernous Malformations: Approach Selection for Minimally Invasive Resection and Systematic Review

Cavernous malformations are benign vascular lesions in the central nervous system with ventricular involvement in less than 10% of cases. Surgical access for safe resection of deep-seated cavernous malformations, particularly to the third ventricle, remains challenging. This study describes a series of 3 patients presenting with symptomatic third-ventricular cavernous malformations (TVCMs) treated at our institution and reviews the available literature pertaining to minimally invasive surgical approaches used to resect these lesions. A prospectively maintained database of patients undergoing surgical management for TVCMs at our institution was reviewed for demographic information, presenting symptoms, and surgical outcomes. For the systematic review, a literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and MeSH search terms. This search strategy yielded 63 articles from PubMed and 31 articles from Embase, yielding 94 articles for review, in total. Three patients were treated for TVCM at our institution, 2 male and 1 female. None of the patients presented with hydrocephalus; however, all were symptomatic with signs of intracapsular hemorrhage. Two patients underwent supraorbital keyhole endoscopic-assisted resection by a translamina terminalis approach. The third patient underwent a right frontal keyhole craniotomy for port-based trans-sulcal exoscopic-assisted resection. Gross total resection was achieved in all 3 patients without complication or permanent memory deficits. The systematic review provided information on 51 additional patients. The most common surgical approaches included interhemispheric transcallosal (26/54, 48.1%) and transcortical transventricular (16/54, 29.6%) craniotomies. Gross total resection was achieved in 46 of 53 patients (86.8%). Postoperative morbidity included permanent memory loss (4, 7.4%), hydrocephalus (4, 7.4%), and death (2, 3.7%). Lesion progression occurred in 4 of 8 patients who underwent subtotal resection. The cases presented here demonstrate the feasibility of selectively adapting minimally invasive neurosurgical techniques, namely the supraorbital translamina terminalis and port-based transcortical approaches, to complement traditional open cranial approaches for the treatment of TVCMs with reasonable safety and surgical outcomes.