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Kasey Trent, 27, presented in the emergency department with a brainstem bleed, which came from a brainstem cavernous malformation (BSCM) that had grown so large that it compressed many important structures harbored within the brainstem. (Read Kasey’s story.) Kasey was transported to the University of Maryland Medical Center, where cerebrovascular neurosurgeon Mohamed A. M. Labib, MD, performed brainstem surgery to remove the BSCM.

Description of the Procedure

An illustration of the patient in a sitting position, showing where the brainstem cavernous malformation was located on the right side of the head behind the ear.

The brainstem cavernous malformation is located mostly in the right side of the brainstem, so surgery is performed on the right side of the patient.

The operation was done in sitting position, which allowed for gravity to displace the cerebellum so the brainstem could be better viewed. The advantage of using gravity is that it is gentler on the brain and minimizes injury to the cerebellum. Manually displacing the brain with instruments can cause damage to the brain.

An illustration depicting where the neurosurgeon performed the craniotomy on the patient.

A craniotomy was performed just behind the patient's right ear. Dura that covered the brain was opened. Under the microscope, spaces between the cerebrum and cerebellum were separated. Important structures encountered on the periphery of the brainstem included superior cerebellar artery (SCA) and 4th cranial nerve (CN IV). These structures were carefully displaced without causing injury.

An illustration of the brain showing the various brain structures from above.

Lateral mesencephalic sulcus (LMS), a groove on the brainstem, was identified. This groove is considered a relatively safe space to access the inside of the brainstem since the brainstem is densely packed with different neural pathways and structures. Staining left by the hemorrhage on the surface of the brainstem and navigation confirmed the location of the BSCM. The groove was opened to remove the BSCM.

Complete resection of the BSCM was achieved.

Further Reading

In the field of cerebrovascular surgery, Dr. Labib has authored multiple articles on complex aneurysm and arteriovenous malformation (AVM) surgeries as well as on new methods of cerebral revascularization. He was also the leading author on the first multicenter study evaluating the efficacy of BrainPath mediated evacuation of intraparenchymal clots, which has evolved into the ENRICH trial.

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