See the corresponding editorial in this issue, p 700.

J Neurosurg 113:701–708, 2010

The presigmoid approach to anterolateral pontine

cavernomas

Clinical article
Erik Friedrich Hauck, M.D., Ph.D., Samuel L. Barnett, M.D.,
Jonathan Ari White, M.D., and Duke Samson, M.D.
Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas

Object. Anterolateral cavernomas of the pons have been surgically removed via a variety of approaches, com-
monly retrosigmoid or transventricular. The goal in this study was to evaluate the presigmoid approach as an alterna-
tive.
Methods. Clinical data were reviewed in 9 patients presenting with anterolateral pontine cavernomas between
1999 and 2007.
Results. All patients were treated via a presigmoid approach, which provided a nearly perpendicular trajectory to
the anterolateral pons. The brainstem was entered through a “safe zone” between the trigeminal nerve and the facial/
vestibulocochlear nerve complex. Complete resection was achieved in all cases. No patient experienced recurrent
events during follow-up (1–24 months). The patients’ modified Rankin Scale score improved within 1 year of surgery
(1.7 ± 0.4) compared with baseline (2.6 ± 0.2; p < 0.05). Only one patient experienced a new deficit (decreased hear-
ing), which was corrected with a hearing aid.
Conclusions. The presigmoid approach is recommended for the resection of anterolateral pontine cavernomas.
With this approach, the need for cerebellar retraction is nearly eliminated. The lateral “presigmoid” entry point cre-
ates a trajectory that allows complete resection of even deep lesions at this level, or anterior to the internal acoustic
meatus. (DOI: 10.3171/2010.1.JNS08413)

Key Words • pontine cavernoma • brainstem cavernoma • presigmoid approach

S
ymptomatic brainstem cavernomas carry a high risk extradural versus intradural anterior petrosectomy (the
of hemorrhage, ranging from 4 to 60% per year.8,11, Kawase quadrilateral approach), transcochlear, trans­
15,19,20,22,26,35
Complete resection, however, may pre- otic, translabyrinthine, transcrusal, retrolabyrinthine
vent the patients’ neurological deterioration by eliminat- (pre­sigmoid), retrosigmoid, far-lateral, transventricular
ing the chance of further hemorrhage or expansion of the (via the fourth ventricle), combined supra/infratento-
lesion.20,35 The focus of the current study is on caverno- rial, and “combined-combined.”2,5–7,10,12,16–18,23–25,29,30,32–34
mas located in the anterolateral pons. Access as the key The exploration of these various options may not only
prerequisite to complete resection is particularly difficult reflect the preferences of various surgeons, but also ad-
in this region. Anterior approaches are hazardous because verse experiences with the traditional approach to an-
of the risk to the corticospinal fibers. Lateral access is re- terolateral pontine cavernomas (the suboccipital expo-
stricted by the labyrinth. Posteriorly, the tegmentum pon- sure).7,10,14,17,20,23,24,29,31,35,36 The goal in this study was to
tis containing the 5th–10th cranial nerve nuclei is a limit. discuss nuances of the various approaches in the context
To circumvent these obstacles, and because of the deep of a series of patients who underwent successful opera-
but central location with potential supra- or infratentorial tions via the presigmoid approach.
access, more approaches to anterolateral pontine cavern-
omas have been suggested than for any other cavernoma
location in the brainstem. The variety of approaches de- Methods
scribed include transsylvian, subtemporal, transtentorial, Patient Population
Between 1999 and 2007, 19 patients presented with
Abbreviations used in this paper: CPA = cerebellopontine angle; pontine cavernomas at the University of Texas Medical
mRS = modified Rankin Scale. Center in Dallas. Nine of these patients, with cavernomas

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 E. F. Hauck et al.

exclusively located in the anterolateral pons, were select- The male/female ratio was 1:8. The median baseline mRS
ed for this study. The remaining patients presented with score was 2. All patients were symptomatic from at least
cavernomas mostly in the posterior pons at the floor of the one neurological event caused by the cavernoma. Eight pa-
fourth ventricle. These were resected via a transventricu- tients (89%) presented with cranial neuropathies resulting
lar approach as previously described by Samii et al.,25 and in double vision, facial numbness or weakness, decreased
are not included in this study. Data on patient demograph- hearing, dysphagia, and dysarthria. Six patients (67%) pre-
ics, cavernoma characteristics, surgical procedures, and sented with a motor deficit ranging from a mild weakness
anatomical details regarding the approach were analyzed to a moderately severe hemiparesis. Sensory deficits were
retrospectively. The patient’s functional condition was as- encountered in 4 patients (44%), and ataxia was found in
certained using the mRS, with a score of 0–2 indicating 5 (56%). Overall the patients were healthy, with only little
a good condition.3,21 The mRS score was determined at medical history. The cavernoma size ranged from 15 to 26
baseline (prior to surgery) after one or multiple neurologi- mm, with a median diameter of 20 mm. All cavernomas
cal events caused by the cavernoma. Then, the mRS score originated in the anterolateral pons.
was assessed again as a final outcome score within 1 year
postsurgery. Approval of this study was granted by the Surgical Technique
institutional review board following the standard protocol
for retrospective reviews of patient charts and electronic In all 9 patients the operation was performed via a
records, in accordance with the Health Insurance Porta- limited presigmoid approach. This approach is similar to
bility and Accountability Act. the petrosal approach for petroclival meningiomas as de-
scribed by Al-Mefty et al.,1 but less expansive and custom-
Statistical Analysis tailored, with focus on the presigmoid window. Monitoring
of the facial nerve and of the somatosensory and brainstem
The statistical analysis was performed using the sta- evoked potentials is standard procedure for all patients.
tistics program SPSS 15.0 (SPSS, Inc.). Demographic data, Positioning is supine with a shoulder roll, or truly lateral.
cavernoma characteristics, surgical procedures, and out- Using a C-shaped cutaneous flap and subperiosteal muscle
come were described for all patients. Frequency and per- dissection, the asterion is exposed. A combined limited sub-
centage values of categorical variables as well as median temporal suboccipital craniectomy or small craniotomy is
and range of continuous variables were determined. A prob- then performed. Removal of mastoid air cells in the antero­
ability value less than 0.05 was considered significant. lateral direction exposes the antrum mastoideum and the
lateral semicircular canal. Medially, the presigmoid dura
Results mater is freed until just behind the posterior semicircular
Patient Characteristics canal (Fig. 1B and D). The dura is opened in a T-fashion
(Figs. 2 and 3), and the tentorium is split to the incisura.
Demographic data, presenting symptoms, and cavern- This dural opening provides ample access to the lateral
oma characteristics are summarized in Table 1. The medi- pons between the facial and trigeminal nerves, with a tra-
an age of the 9 patients enrolled in the study was 37 years. jectory nearly perpendicular to the brainstem (Figs. 2 and

TABLE 1: Clinical data in 9 patients undergoing resection of an anterolateral pontine brainstem cavernoma via the
presigmoid approach*

Case Age (yrs), Lesion Size mRS Score

No. Sex Side (mm) Presentation Preop Postop† Complications FU (mos)
1 14, F rt 22 CND, MD, SD, ataxia 2 2 none 1
2 31, F lt 18 CND, MD, SD 3 2 none 19
3 32, F lt 20 HA, ataxia 2 0 none 1
4 34, F lt 24 HA, CND, MD, SD, ataxia, vertigo 3 3 none 5
5 37, F lt 16 HA, CND, MD 2 2 none 21
6 47, F rt 25 CND, MD, vertigo 3 0 CSF leak 3
7 59, M lt 26 HA, CND 2 1 none 20
8 66, F lt 15 CND, ataxia 2 1 none 5
9 72, F lt 15 CND, MD, SD, ataxia, vertigo 4 4 infection & hearing loss 24
median 37 20 2 2 5
min 14 15 2 0 1
max 72 26 4 4 24

* CND = cranial nerve deficit; FU = follow-up; HA = headache; MD = motor deficit (ranging from mild weakness to moderately
severe hemiparesis); SD = sensory deficit.
† Within 1 year postoperatively.

702 J Neurosurg / Volume 113 / October 2010

Pontine cavernomas

Fig. 1. A: Preoperative CT scan (soft-tissue window) demonstrating Fig. 2. Intraoperative photographs illustrating a right-sided presig-
a left CPA hyperdense mass, a pontine cavernoma measuring 26 mm in moid approach for the resection of a pontine cavernoma. A: Dural
the largest diameter. B: Postoperative CT scan (soft-tissue window) exposure viewed through the operating microscope following a small
showing resection of the mass with decompression of the CPA via a suboccipital and subtemporal craniectomy/craniotomy, a mastoidec-
presigmoid approach with craniectomy and abdominal fat grafting. C: tomy, and posterior petrosectomy. The photograph is centered on the
Preoperative CT scan corresponding to A (bone window). The dotted presigmoid dura mater (δ). The sigmoid sinus (σ) is exposed at the
line is tangential to the surface of the pons. The solid white line denotes bottom of the photograph (posterior margin). The ear (ε) is reflected
the suboccipital trajectory to the point where the cavernoma reaches anteriorly. The antrum (α) constitutes the anterolateral limit of the expo-
the surface of the pons. Note the flat angle (marked with “α”) of the sure. Anteromedially, the posterior semicircular canal (π) is left intact to
suboccipital trajectory toward the lesion. D: Postoperative CT scan preserve hearing. The so-called roof of the exposure is represented by
corresponding to B (bone window). Note the extent of the mastoidecto- the temporal dura (τ). B: High-power magnification microscopic view
my/posterior petrosectomy, with preservation of the semicircular canals of the intradural “presigmoid” exposure after opening of the presigmoid/
and the patient’s hearing. The posterior semicircular canal is the poster- temporal dura and division of the superior petrosal sinus and tentorium.
omedial limit of the retrolabyrinthine exposure. The lateral semicircular The exposure gains access to the anterolateral pons viewed between
canal and antrum constitute the anterior border. The dotted line is tan- the trigeminal nerve (5) and the facial/vestibulocochlear nerve complex
gential to the surface of the brainstem. The solid white line indicates the (7/8). The view to the Obersteiner-Redlich zone of the vestibulocochlear
presigmoid trajectory. Note the improved angle (marked with “β”) of the nerve is partly obscured by bulging choroid plexus from the foramen of
presigmoid trajectory, which is more perpendicular to the surface of the Luschka. The labyrinthine branch of the anterior inferior cerebellar ar-
pons, thus facilitating complete resection of even deeper lesions. E: tery can be seen immediately beneath the vestibular nerve. Note that in
Preoperative CT scan corresponding to A (bone window). The dotted this case neither a discoloration nor a little prominence at the brainstem
lines demonstrate the suboccipital and presigmoid trajectories. The surface indicated the precise location of the cavernoma. C: After a
solid line (marked with “δ”) demonstrates the lateral expansion gained longitudinal incision into the so-called safe entry zone between the
with the presigmoid compared with the suboccipital approach. trigeminal nerve and the facial/vestibulocochlear nerve complex, the
cavernoma is encountered and completely removed. Bar = 1 cm.
4). Typically, the cavernoma presents itself at the surface as
slight or more obvious discoloration or small prominence. a dark red or purple mass.4,5 The entire cavernoma is then
In some cases, however, no visible clue may reveal the pre- removed in piecemeal fashion and the wound is closed.
cise location of the cavernoma (Fig. 2). Based on the vis-
ible pathological entity and/or anatomical landmarks, an Postoperative Course and Outcome
incision is made parallel to the long axis of the brainstem After 24-hour observation in the intensive care unit,
immediately over the cavernoma; neuronavigation may the patients were transferred to the regular floor. The me-
be helpful for this step. The cavernoma presents itself as dian hospital stay was 6 days (range 4–7 days; one patient

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 E. F. Hauck et al.

Fig. 3. Artist’s rendering of the dural exposure with a right-sided presigmoid approach. The T-shaped dural incision is marked.
The dotted line represents the last dural cut crossing the superficial petrosal sinus. Opening of the labyrinth is not required for
full exposure of the safe entry zone of the anterolateral pons for cavernoma resection. Lat = lateral; post = posterior; sup =
superior.

stayed 22 days). The patients then were followed for a deficit postoperatively; specifically, on the side of the sur-
median of 5 months (range 1–24 months). In all patients, gery, a 72-year-old woman had decreased hearing, which
no residual tumor was evident at the end of the surgical was corrected with a hearing aid. Five patients improved
procedure intraoperatively or on postoperative imaging beyond their baseline neurological status. The median
(Fig. 5). Only one patient developed a new neurological mRS score was 2 within the 1-year follow-up period, with

Fig. 4. Artist’s sketch of the intradural anatomy visualized through a right-sided presigmoid approach. The entry zone to deep
lesions within the anterolateral pons is in the center of the field. No cerebellar or temporal (vein of Labbé) retraction is required.
The trajectory is nearly perpendicular to the surface of the pons, facilitating complete resection of even deep lesions. CN = cranial
nerve.

704 J Neurosurg / Volume 113 / October 2010

Pontine cavernomas

Lateral Approaches (Presigmoid)

In a large series of 86 patients treated surgically for
brainstem cavernomas, Porter et al.20 used the presigmoid
(retrolabyrinthine) approach in 5 patients and a combined
supra/infratentorial approach in 3 patients, with good out-
comes. In 3 cases, Porter et al. used a more extensive pet-
rosectomy variation, including the resection of the cochlea
and/or the labyrinth. With the more extensive petrosecto-
my variants, the risk of hearing loss is obviously increased,
even though it may be as low as 10–20% with a partial
labyrinthectomy (transcrusal).27,28 Oiwa et al.17 reported 2
cases of pontine cavernomas that were resected success-
fully via the presigmoid approach. In a comment to the
Oiwa article, Al-Mefty et al.1 briefly report their own posi-
tive experience with the presigmoid approach for the resec-
tion of pontine cavernomas. In their series of 36 patients
with complete resection of brainstem cavernomas, Samii et
al.25 used the presigmoid approach as well in one case that
they described as anterolateral. Based on these reports and
our own experience, the limited presigmoid approach (ret-
rolabyrinthine) appears to be practical, and we recommend
it for the resection of anterolateral pontine cavernomas.
Posterior Approaches (Retrosigmoid, Transventricular)
The retrosigmoid approach is technically straightfor-
Fig. 5. A: Preoperative T1-weighted Gd-enhanced MR image. Note ward. However, the angle of the retrosigmoid trajectory
the 26-mm heterogeneous mass consistent with a pontine cavernoma is shallower compared with the presigmoid, possibly pre-
at the level of the facial/vestibulocochlear nerve complex on the left venting complete resection of intrinsic and deeper lesions
side. B: Postoperative T1-weighted Gd-enhanced MR image cor- (Figs. 1 and 6). If significant retraction is required, the
responding to A. The cavernoma has been resected without residual risk of injury to the brainstem and cranial nerves may be
lesion. An abdominal fat graft was used for closure of the presigmoid
craniectomy. C: Preoperative T1-weighted Gd-enhanced MR image increased.2,31,34 However, several authors report good suc-
obtained in a second patient. Note the 25-mm heterogeneous mass cess with the retrosigmoid approach.9,20,32,35,36 Steinberg et
consistent with a pontine cavernoma slightly above the level of the fa- al.30 preferred the far-lateral extension of the retrosigmoid
cial/vestibulocochlear nerve complex on the right side. D: Postopera- approach, with excellent results for the resection of an-
tive T1-weighted Gd-enhanced MR image corresponding to C. terolateral pontine lesions, particularly in lower lesions
extending into the medulla. In the largest surgical series
scores ranging from 0 to 4. The postoperative compared of pontine cavernomas, Wang et al.35 used the retrosig-
with preoperative mRS score was significantly improved moid approach, with good success. Due to the improved
overall (p < 0.05). One patient developed a CSF leak that trajectory with less need for brain retraction, we favor the
subsided after 4 days of lumbar drainage. One patient presigmoid over the retrosigmoid approach for the resec-
developed a wound infection that resolved with incision, tion of anterolateral pontine cavernomas.
drainage, and antibiotic therapy. The transventricular approach is ideal if a pontine
lesion reaches the floor of the fourth ventricle (posterior
pontine). Samii et al.25 used the transventricular approach
Discussion as their standard method, with low morbidity for the resec-
The first resection of a CPA cavernoma was not earli- tion of 36 brainstem cavernomas, with the exception of one
er than in 1986.9 Since then, approximately 200 surgically case, a cavernoma located anterolaterally. They achieved
treated cases with resection of anterolateral pontine cav- complete resection in all cases. Wang et al.35 reported good
ernomas have been reported (Table 2). Most authors agree outcomes with a large series of patients whose lesions were
on a transventricular approach to dorsal pontine caverno- resected through the fourth ventricle. Mao et al.14 described
mas abutting the floor of the fourth ventricle.6,16,20,25,31,35 the transventricular approach as “easy.” However, access to
In contrast, a large variety of approaches has been used anterolateral lesions via the fourth ventricle requires open-
for anterolateral pontine lesions, with varying suc- ing of the floor of the fourth ventricle, with potential injury
cess.2,5–7,10,12,17,18,23–25,29,32–34 Initially, anterolateral pontine to the nuclei of the 5th–10th cranial nerves. Ferroli et al.7
cavernomas were approached via a suboccipital craniec- noted a fairly high permanent morbidity after creating an
tomy.2,5,9,14,18,31,32,36 Since 1999, skull base approaches have opening within the floor of the fourth ventricle. Their per-
been applied to eliminate some of the problems with the manent morbidity rate with the transventricular approach
traditional methods.1,16,20,28 In the following discussion, was 36%, even though they consequently used “safe-zone”
various approaches to anterolateral pontine cavernomas entry points within the supra- or infrafacial trigones as de-
and treatment options are presented. scribed by Kyoshima et al.13 Porter et al.20 had a low overall

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 E. F. Hauck et al.
TABLE 2: Literature review of approaches used for resection of anterolateral pontine cavernomas*

No. of Lesion Residual New Permanent

Authors & Year Patients Location Approach† Lesion Deficit Morbidity
Iplikçioğlu et al., 1986 1 ALP retrosigmoid
Vaquero et al., 1987 1 pons poor outcome 1:1
Kumabe et al., 1988 1 ALP subtemporal transtentorial
Zimmerman et al., 1991 5 ALP suboccipital (1)
ALP combined (3)
ALP subtemporal (1)
Bertalanffy et al., 1991 3 ALP retrosigmoid (1) hearing loss 1:1
transventricular (2)
Fahlbusch & Strauss, 1991 6 pons transventricular double vision 1:6
Symon et al., 1991 4 ALP retrosigmoid (1) hemiparesis 1:1
transventricular (3) none
Tokumitsu et al., 1993 1 ALP retrosigmoid
Fritschi et al., 1994 2 ALP
Endo et al., 1997 1 ALP transventricular

Porter et al., 1999 15 ALP retrosigmoid

retrolabyrinthine
translabyrinthine
transcochlear
combined
Okuno et al., 2000 1 ALP retrosigmoid 1:1
Steinberg et al., 2000 24 pons transventricular
retrosigmoid far lat
subtemporal/anterior petrosectomy
Mao et al., 2001 12 pons transventricular (11) facial weakness 2:11
transpetrosal (1)
Samii et al., 2001 1 AL presigmoid (1)
28 pons transventricular
Saito et al., 2002 1 ALP anterior petrosectomy
Oiwa et al., 2002 2 ALP presigmoid (2)
Wang et al., 2003 83 pons retrosigmoid
transventricular
Roszkowski et al., 2003 5 ALP transsylvian 1:5
Ferroli et al., 2005 17 ALP retrosigmoid (15) 1:17
presigmoid (2)
Kashimura et al., 2006 1 ALP subtemporal/anterior petrosectomy
Steiger et al., 2006 3 ALP subtemporal/anterior petrosectomy 2:3 decreased hearing 1:3
present study 9 ALP presigmoid (9) decreased hearing 1:9

* Blanks denote information not specified by authors. Abbreviations: ALP = anterolateral pons; pons = unspecified location in the
pons.
† Number in parentheses denotes the number of patients treated via the approach.

complication rate, but recommended a “healthy respect” the presigmoid approach should be considered as an alter-
for the floor of the fourth ventricle, particularly in the area native, particularly if the lesion is deep to the floor of the
of the facial colliculus. Okuno et al.18 reported limitations fourth ventricle.
with the transventricular approach in a case of a recurrent
cavernoma. In summary, the transventricular approach is Anterior Approaches (Transsylvian, Kawase)
the standard one for posterior pontine lesions at the floor Several authors described a more anterior approach to
of the fourth ventricle. For anterolateral lesions, though, anterolateral pontine cavernomas (Table 2).12,23,29,30 Rosz-

706 J Neurosurg / Volume 113 / October 2010

Pontine cavernomas

resection of lesions located primarily in the anterior mid-

brain.

Conclusions
The presigmoid approach is practical for the resec-
tion of anterolateral pontine cavernomas. The need for re-
traction is nearly eliminated. The more lateral entry point
(presigmoid) creates a trajectory more perpendicular to
the surface of the pons. The incision into the lateral pons
(safe zone) provides a low-morbidity access to the lesion.

Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.

Acknowledgments
The authors thank Jerri Thomas for her support and Suzanne
Truex “Jorlam” for her drawings.

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26. Sandalcioglu IE, Wiedemayer H, Secer S, Asgari S, Stolke lished online March 19, 2010; DOI: 10.3171/2010.1.JNS08413.
D: Surgical removal of brain stem cavernous malformations: Address correspondence to: Erik F. Hauck, M.D., Ph.D., De­­part­
surgical indications, technical considerations, and results. J ment of Neurosurgery, University of Texas Southwestern Medical
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