AUTHOR=Agyemang Kevin , Gómez Rodríguez Rony , Rocha Marussi Victor Hugo , Marte Arias Sally Allinson , Feliciano Vilcahuaman Paitań Alexander , Campos Filho José Maria , Chaddad-Neto Feres 

TITLE=Case report: Delayed outflow obstruction of a DVA: A rare complication of brainstem cavernoma surgery

JOURNAL=Frontiers in Neurology

VOLUME=Volume 14 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1073366

DOI=10.3389/fneur.2023.1073366

ISSN=1664-2295

ABSTRACT=Introduction - Developmental venous anomalies (DVAs) are considered variants of normal transmedullary veins. Association with cavernous malformations is reported to increase the risk of hemorrhage.
Expert consensus recommend meticulous planning with MR imaging, use of anatomical “safe zones”, intraoperative monitoring of long-tracts and cranial nerve nuclei and preservation of the DVA as key to avoiding complications in brainstem cavernoma microsurgery.
Symptomatic outflow restriction of a DVA is extremely rare with most of the limited cases restricted to the supratentorial compartment. Hemorrhagic and ischemic sequelae have both been observed, although the latter is more common.
Case - We present a case report of the resection of a pontine cavernoma complicated by delayed outflow obstruction of the associated DVA. 
The patient presented with progressive left-sided hemisensory disturbance and mild hemiparesis. MRI revealed two pontine cavernomas associated with interconnected DVA and hematoma. The symptomatic cavernoma was resected via the infrafacial corridor. Despite preservation of the DVA, the patient developed delayed deterioration secondary to venous hemorrhagic infarction.
We discuss the imaging and surgical anatomy pertinent to brainstem cavernoma surgery, as well as the literature exploring the management of symptomatic infratentorial DVA occlusion.
Conclusion – Delayed symptomatic pontine venous congestive edema is extremely rare following cavernoma surgery. DVA outflow restriction from a post-operative cavity, intra-operative manipulation and intrinsic hypercoagulability from COVID-10 infection are potential pathophysiological factors. Improved knowledge of DVAs, brainstem venous anatomy and “safe entry zon”s" will further elucidate the etiology of and the efficacious treatment for this complication.