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Figure Captions
Fig. 1. Preoperative magnetic resonance imaging (MRI) of the patient. A lesion with
heterogeneous signal intensity was detected in the fourth ventricle. Hydrocephalus was not
apparent. A) Gadolinium (Gd)-enhanced T1-weighted sagittal imaging and B) T2-weighted
sagittal imaging. MRI obtained 4 months after the first MRI showed enlargement of the lesion.
The alteration in the signal intensity of the lesion suggested repeated hemorrhage. The presence
of a hemosiderin rim on T2-weighted imaging indicated that the lesion was a cavernoma. C) Gdenhanced T1-weighted sagittal imaging and D) T2-weighted sagittal imaging.
Fig. 2. A) Head fixation of the patient during surgery. The head was rotated approximately 10
degrees to the side of the surgeon to facilitate the insertion and removal of the surgical
instruments and neuroendoscope. B) Schematic of the surgical corridor. A tubular retractor was
introduced into the fourth ventricle from a more caudal side than that in conventional
microscopic surgery to minimize retraction of the cerebellum. C) Photograph of a 5.8-mm
transparent acryl puncture needle (black arrow) and a 6.8-mm transparent sheath (white arrow).
D) A 2.7-mm, rigid neuroendoscope can be inserted in the puncture needle, which enables sheath
insertion under endoscopic observation. E-H) Intraoperative findings by the “wet-field”
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technique. By continuous irrigation with artificial cerebrospinal fluid (CSF), the ventricular size
was maintained, and the lesion and the surrounding brain tissue were well exposed. The black
asterisk in E and H shows an irrigation tube for continuous irrigation with artificial CSF. E) The
lesion was not adhered to the pons and was successfully detached from it. F) The attachment of
the lesion was detected on the superior medullary velum. G) The lesion was completely removed
with preservation of the venous anomaly on the aqueduct of Sylvius (white arrow). H) After
tumor resection and sheath removal, no tissue trauma was detected in the cerebellar vermis
(white asterisk) or bilateral tonsils. Cav: cavernoma, SMV: superior medullary velum, Ton:
tonsil.
Fig. 3. Postoperative gadolinium (Gd)-enhanced T1-weighted sagittal imaging 6 months after the
surgery. The fourth ventricular lesion was completely removed with preservation of the venous
anomaly (white arrow) on the aqueduct of Sylvius.
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