Microsurgical excision of giant dominant lobe insular cavernoma presenting acutely: Sometimes you win, sometimes you learn

Abstract

Introduction: Eloquent location and difficult access make insular surgery challenging. Thus operative adjuncts like neuronavigation, intraoperative monitoring and awake surgery are now considered the standard of care for these lesions. However, these may not be possible in all cases and resource constraints may place limits to what could be achieved. There still remains a possibility of achieving reasonable results with good surgical technique and meticulous surgery. Case report: We report 2 cases of giant (>6 cm) left insular cavernoma, excised using pterional-transylvian-transinsular approach, in a resource constrained and emergency setting. Both the cases had a sudden presentation with one case presenting with sudden increase in hemiparesis while the other presented with headache resulting from bleed in the background of a history seizures for 6 months. While clearing the clot in the first case, the hemosiderin rim was removed while it was deliberately avoided in the second patient. While the first case developed neurological worsening after surgery, eventually improving at follow-up, the postoperative course was uneventful in the second patient. Postoperative scan revealed a complete cavernoma excision in both the patients. Conclusion: Operating outside ideal conditions is always challenging, but not impossible. Spontaneous hemorrhage in and around these lesions may also be a blessing in disguise during surgery. While we do not advocate this as the ideal methodology, emergent conditions and lack of gadgets often necessitate evasive action and push ourselves. A combination of sound anatomical knowledge and experience in operating in this area can allow their safe excision with considerable safety. Considering the global neurosurgical burden and paucity of skilled manpower and resources, an undertaking of such a nature might be helpful to other readers in similar conditions. Keywords: Cavernoma, Insula, Microneurosurgery, Neuromonitoring