Electrocardiogram Synchronized Physiological Feedback During Obex Cavernoma Surgery: 2-Dimensional Operative Video.

This operative video presents a physiology-guided strategy for resection of a right paramedian obex cavernoma in a 57-year-old man with intractable hiccups, progressive dysphagia with aspiration, and hoarseness. Magnetic resonance imaging showed interval enlargement and recurrent hemorrhagic evolution, exophytic presentation to the caudal fourth ventricle, and an associated developmental venous anomaly. Because continued observation carried a risk of recurrent hemorrhage and worsening bulbar dysfunction, resection was performed through a midline suboccipital telovelar approach with multimodal monitoring. The video is intended as a practical teaching case rather than a proposal of a new physiological boundary or an argument for surgery in all obex region lesions. It demonstrates how electrocardiogram-synchronized cardioinhibitory responses can prompt immediate cessation of manipulation, full rhythm recovery, additional internal decompression, reduced traction, and resumption with smaller and sharper maneuvers. Gross total resection was achieved with preservation of the venous anomaly. The patient had complete resolution of choking sensation, no new lower cranial nerve deficit, no residual lesion on 3-month imaging, and a small asymptomatic extradural/subcutaneous fluid collection that gradually regressed with observation alone. The patient consented to publication.