The Posterior Transylvian Peri-Insular Approach to a Cavernous Malformation of the Pulvinar Thalamus: 2-Dimensional Operative Video

Posterolateral thalamus is a deep structure comprised pulvinar, lateral, and medial geniculate. Safe surgical access to this region centers on bringing the structure to the surface with the chosen approach. Cavernous malformation of the thalamus is among the most difficult to surgically manage due to the eloquent nature and depth of this location.1 They account for 9% to 35% of all cerebral cavernous malformation2 and are recognized along with other deep-seated cavernomas to have a high rate of symptomatic hemorrhage.3 Posterior lateral thalamus and atrium of the lateral ventricle can be accessed through the transcallosal transventricular, intraparietal sulcus, supracerebellar transtentorial, and transcortical approaches. The surgical approach can affect morbidity and outcomes due to factors such as the structures at risk, working space, and distance.4-10 The ubiquitous availability of neuronavigation does not eliminate the need for a good understanding of the surface anatomy of the brain and its relationship to the deep structures of the central core. We discuss a step-by-step guide to using the inferior Rolandic point and Heschl and supramarginal gyri to safely navigate to the pulvinar and atrium. The patient, a woman in her 30s, presented with sudden clinical alteration of the left face, arms, and legs. This was associated with alteration of the visual field. Computed tomography and MRI revealed a cerebral cavernous malfor-mation in the pulvinar thalamus. The patient consented to the procedure and to the publication of his/her image. We show how posterior transsylvian peri-insular trajectory provides a wide and shallow working corridor to safely resected this cavernoma with no additional deficits.