The three variations of the supracerebellar infratentorial (SCIT) approach (midline, lateral, and extreme lateral), especially when coupled with image guidance, provide safe trajectories to deep-seated complex cavernous malformations (CMs) of the midbrain, which pose a high risk of incurring severe disability.

Case 1, a 27 year old female with severe headaches and Parinaud's syndrome caused by a CM in the pineal region, underwent a midline SCIT approach. Case 2, a female with moderate deficits from three hemorrhages caused by a large CM that extended to the surface of the posterolateral midbrain and Case 3, a 32 year old female with sensorimotor deficits from a CM located in the anterior midline aspect of the midbrain, both underwent lateral SCITS. Case 4, a 67 year old male, who had undergone a previous attempt to resect his brainstem CM via a subtemporal approach, developed progressive disabling symptoms. An extreme lateral SCIT was used to resect his large, multicompartmental lesion.

Postoperative imaging confirmed complete resection in all four cases. Case 1 experienced cerebellar mutism for 2 days and was neurologically intact on Day 3. Cases 2 and 3 experienced transient worsening of their preoperative symptoms and then made excellent recoveries. Case 4 eventually regained independent ambulation, and his balance improved considerably.

The SCIT can be used to obtain complete resection of deep-seated CMs while minimizing dissection and retraction of brain tissue. Associated venous anomalies must be preserved to avoid potentially devastating infarcts. Morbidity rates are acceptable and outcomes can be excellent.