Telovelar approach for resection of a pons metastasis: Three-dimensional surgical video

Although metastases are the most common type of brain tumors, only 3-7% of them affect the pons. Due to its rarity and the high surgical morbidity, most cases are treated with radiotherapy; however, in selected cases, surgery can bring benefits such as improving the mass effect, local control of the disease, and avoiding the high risk of late neurological deficits caused by the scatter of radiation in radiotherapy treatment.

We present a 72-year-old female with a history of 3 weeks of progressive dizziness and a decrease in sensitivity. The physical examination had a positive Romberg test. The neurologic investigation was performed by magnetic resonance imaging, which showed a unique pontine tumor with peripheral contrast enhancement and a necrotic center. Brain stem tractography revealed lateral displacement of sensitive fibers, allowing a safe approach to the tumor through the floor of the fourth ventricle. A microsurgical resection through a telovelar approach was proposed. The patient showed no worsening of symptoms, and a postoperative MRI revealed complete lesion resection. Tumor biopsy confirms lung metastasis diagnosis.

In this three-dimensional video, the authors present step-by-step microsurgical techniques for performing a pontine metastasis resection using a telovelar approach. It is essential to emphasize that technical and anatomical knowledge, combined with adequate patient selection, are crucial for achieving optimal results in cases of brainstem metastases.