J Cerebrovasc Endovasc Neurosurg.  2023 Sep;25(3):316-321. 10.7461/jcen.2023.E2022.03.004.

Awake craniotomy removal of a corticospinal tract developmental venous anomaly hemorrhage: A case report

• Barrenechea IJ
• Márquez LM
• Cortadi VA
• Rojas HP
• Ingledew R

• KMID: 2546169
• DOI: http://doi.org/10.7461/jcen.2023.E2022.03.004

Abstract

Developmental venous anomalies (DVAs) are composed of mature venous vessels that lack malformed or neoplastic elements. Although the hemorrhage risk is considered negligible, some patients may have neurological symptoms attributable to acute infarction or intracranial hemorrhage secondary to thrombosis, in the absence of a coexisting cavernous malformation. We report the case of a 42-year-old patient who presented with acute left-hand paresis secondary to a subcortical hemorrhage. This bleeding originated from a DVA in the corticospinal tract area and was surgically drained through an awake craniotomy. To accomplish this, we used a trans-precentral sulcus approach. After the complete removal of the coagulum, small venous channels appeared, which were coagulated. No associated cavernoma was found. Although the main DVA trunk was left patent, no signs of ischemia or venous infarction were observed after coagulating the small venous channels found inside the hematoma cavity. Two weeks after the procedure, the patient’s hand function improved, and he was able to resume desktop work. DVA-associated hemorrhage within the cortico-spinal tract could be safely removed with modern awake mapping techniques. This technique allowed the patient to rapidly improve his hand function.

Keyword

Developmental venous anomaly; Cavernous malformation; Eloquent cortex; Cerebral hemorrhage; Magnetic resonance imaging; Manual dexterity

Figure

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  Fig. 1. (A) Axial T2-weighted magnetic resonance imaging (MRI) revealing a 4-cc hypointense lesion. An irregular hyperintense perilesional rim was observed. This lesion was located subcortically, within the corticospinal tract. (B) Axial T2-weighted MRI showing edema at the level of the hand knob. (C) Sagittal non-contrast T1-weighted MRI revealing a hyperintense mass. (D) Coronal SWI-weighted MRI. A developmental venous anomaly is visualized adjacent to the hemorrhage. (E and F) MRI tractography of the corticospinal tract. Note that the hand fibers were spread out by the hemorrhage.

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  Fig. 2. The patient was operated on awake. (A) Initial step with a nasal cannula. EMG electrodes were placed in his upper and lower extremities. (B) Intraoperative photograph showing the planned craniotomy. A right lazy S incision and frontoparietal craniotomy were performed. (C) Microscopic photograph showing the initial cortical exposure. Note the hand knob (black star) and precentral sulcus (white arrow). (D and E) High-frequency monopolar cortical mapping of the precentral gyrus and sulcus. (F) Exposure of the hemorrhage after opening the precentral sulcus. Several venous channels (white arrow) were found and thoroughly coagulated within the hematoma. No cavernous malformation was found within or adjacent to the hematoma cavity. (G) On hematoxylin and eosin sections, there are small to medium-sized blood vessels and macrophages containing hemosiderin pigment (40×).

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  Fig. 3. (A) Eight-month axial T2-weighted magnetic resonance imaging (MRI) showing complete resolution of the hemorrhage. (B) Axial T2-weighted MRI at the level of the hand knob. Note mild atrophy of this cortical area. (C and D) MRI tractography of the corticospinal tract. Note the proximity of the resection cavity (white arrow) with this structure. (E) Coronal T1-weighted contrast-enhanced MRI. The main developmental venous anomaly remains patent (white arrow).

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