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P184: INTERNAL CEREBRAL VEIN INJURY DURING PINEAL REGION EPIDERMOID CYST RESECTION: CASE REPORT AND NATURAL HISTORY
Alankrita Raghavan, MD; Kennedy Carpenter, MD; Stephanie Greene, MD; Duke University

Injury to the internal cerebral vein (ICV) during neurosurgical procedures is an exceedingly rare and poorly characterized event. The deep venous system, which includes the ICVs, is responsible for draining critical structures such as the thalami, basal ganglia, corpus callosum, and deep white matter. Given their anatomical proximity to the pineal region, the ICVs are at particular risk during approaches to pineal and posterior third ventricular lesions, but there is no literature on the natural history or long-term outcomes following direct iatrogenic injury. Here, we report the case of a 14-year-old male who sustained an intraoperative right ICV injury requiring sacrifice during resection of a pineal region epidermoid cyst, providing rare insight into the clinical course and recovery following such an event.

The patient presented with progressive headaches and was found to have an enlarging pineal region epidermoid cyst (Figure 1). He underwent resection via a supracerebellar, infratentorial approach, during which the right ICV was injured and ultimately sacrificed. Postoperatively, he developed bilateral thalamic infarcts and transient neurological deficits, including left-sided hemiparesis, mutism, and dysphagia requiring a gastrotomy tube (Figure 2). Despite the initial severity of these findings, the patient demonstrated remarkable recovery with supportive management, inpatient rehabilitation, and multidisciplinary care. By six weeks, he had regained near-complete motor strength, his gastrostomy tube was removed following improvement in swallowing function, and he was able to return to school. At three months, he exhibited only minimal residual weakness, and by eight months, neurological examination was normal and he had no deficits. Follow-up imaging confirmed stroke evolution and chronic thrombosis of the right ICV without new complications (Figure 2).

While ICV injury has traditionally been considered catastrophic due to the risk of bilateral thalamic infarction, our patient’s recovery suggests that meaningful neurological improvement is possible under certain anatomical and physiological conditions, likely mediated by contralateral venous drainage and collateral circulation. Second, it emphasizes the importance of vigilant preoperative planning with careful assessment of venous anatomy, as well as intraoperative awareness when operating in the pineal region. Finally, the case underscores the role of early postoperative imaging, maintenance of stable hemodynamics, and aggressive multidisciplinary rehabilitation in optimizing recovery.

Review of the limited literature on ICV thrombosis suggests a variable clinical spectrum ranging from mild headaches to severe deficits or death. However, most reports describe thrombotic occlusion rather than direct surgical injury, leaving the natural history of iatrogenic ICV sacrifice largely unexplored. Our report, therefore, adds novel data on the potential for favorable outcomes in pediatric patients, challenging the assumption that deep venous injury uniformly results in devastating deficits. This case suggests that iatrogenic injury to the ICV, though morbid initially, is survivable with good functional recovery under select conditions. Further study is warranted to define the determinants of prognosis following deep venous injury.

Figure 1

Figure 2.

 

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