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: This video illustrates the case of a patient with familial cerebral cavernous malformation syndrome with a history of multiple symptomatic hemorrhages attributable to a medullary malformation. The patient had swallowing difficulties and gait instability that was progressively worsening. Informed consent was obtained for surgical exploration. The lesion was noted to abut the floor of the fourth ventricle and was approached using a suboccipital craniotomy. Several safe-entry zones on the floor of the fourth ventricle have been described. For lesions that abut the floor, or those that are exophytic, a direct point of entry into the lesion is selected. When possible, the opening into the floor of the fourth ventricle should be placed off midline. The technique of piecemeal resection of the lesion from the brainstem and preservation of normal, hemosiderin-stained brain is presented. Careful patient selection and respect for normal anatomy are of paramount importance in obtaining excellent outcomes in operations within or adjacent to the brainstem. This medullary lesion was resected completely.

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