Two Cases of Direct Surgery for Brainstem Cavernous Malformation with Recurrent Bleeding over a Short Period

Brainstem cavernous malformations (BCMs) presenting with hemorrhage are known to have a higher risk of rebleeding than cavernous malformations in other locations. We report two cases of BCMs with recurrent bleeding and gradual neurological deterioration over a short period treated with emergency operations. The first case was a 46-year-old-man presenting with sudden vertigo and intra-fourth-ventricular hemorrhage demonstrated by computed tomography (CT). Over two weeks, the patient's consciousness level declined, and associated CT images showed a gradually increased hemorrhage size. Consequently, emergency operation via a midline suboccipital approach was performed on day 15. Intraoperative findings were consistent with a diagnosis of a rare intra-fourth-ventricular cavernous malformation. The second case was a 45-year-old man presenting with a sudden onset of left motor and sensory disturbances. CT showed pontine hemorrhage. Symptoms of neurological decline and radiologically identified rebleeding were observed, and an emergency operation via the midline suboccipital approach was performed on day 16. Surgical management is typically recommended for BCMs presenting with hemorrhage due to the high risk of rebleeding and morbidity, and emergency operation is sometimes necessary, as in these cases.