Symptomatic cavernous malformations of the brainstem: functional outcome after microsurgical resection

Contralateral Interhemispheric Transcallosal Approach for Thalamic Cystic Cavernous Malformation

A 42-year-old man presented with a headache and right hemiparesis and was found to have a cystic mass with a calcified mural nodule in the left thalamus. Because the thalamus is surrounded by vital neurovascular structures, the surgical approach to thalamic lesions can be challenging. We decided to remove the mass for decompression and pathological diagnosis. The mass was removed through a contralateral interhemispheric transcallosal transchoroidal approach with less retraction and parenchymal injury than other approaches to avoid brain retraction and cortical injury. The pathological diagnosis was cavernous malformation. Temporary worsening of the preoperative hemiparesis was recovered over two months following surgery. Tolerable thalamic pain syndrome remained. Here, we report a rare case of thalamic cavernous malformation with a favorable outcome through a contralateral surgical approach.

The benefit and outcome prediction of acute surgery for hemorrhagic brainstem cavernous malformation with impending respiratory failure

OBJECTIVES

Impending respiratory failure is catastrophic neurological deterioration caused by repeated c of a brainstem cavernous malformation (BSCM). The benefit and outcome prediction of acute surgery for this fatal condition is rarely reported. In this study, the authors reported a case series of acute surgical treatment (≤3 weeks after the last hemorrhagic episode) for the BSCM with impending respiratory failure and reviewed literature over the past 20 years.

MATERIALS AND METHODS

Clinical and outcome data from 6 consecutive acute surgically-treated BSCM patients were analyzed. Intracerebral hemorrhage (ICH) scores, primary pontine hemorrhage (PPH) scores, and Lawton's BSCM grading were applied for surgical outcome prediction. Ten related articles were included for the literature review.

RESULTS

There were three men and three women, with a mean age of 32.2 ± 9.3 years (range 15-45 years). The BSCMs were located at the pons in 5 cases and the medulla in 1 case. The ICH score was 1-2 in all cases, while the PPH score was 0 in all pontine BSCMs. For Lawton's BSCM grading, 3 cases were grade 2, 2 cases were grade 3, and 1 case was grade 1. All patients achieved spontaneous respiratory dysfunction relief postoperatively and significantly improved at follow-up (mean 4.47 ± 0.24 years;range4.0-5.6 years).

CONCLUSIONS

Repeated hemorrhagic BSCM with impending respiratory failure can benefit from acute surgical treatment. The ICH score, PPH score, and Lawton's BSCM grading are promisingly useful tools for fast and efficient surgical outcome prediction.

Holmes tremor in a monocentric series of resected brainstem cavernomas

OBJECT

Several scientific papers report clinical symptoms, indications, complications and outcomes of brainstem cavernous malformation (BSCM) surgery without reporting on the occurrence of postoperative Holmes tremor (HT). Our purpose is to report our experience with HT in a monocentric series of resected brainstem cavernomas.

METHODS

We reviewed all the BSCM surgical records between 2002 and 2018 at Saint-Luc University Hospital's Department of Neurosurgery, Brussels and selected patients developing HT postoperatively. Patients' demographics, symptoms, pre- and postoperative imaging, recurrence and complications were analysed. A PubMed literature review was performed to compare our results with those in the existing literature.

RESULTS

In a total series of 18 resected BSCM, 5 patients: 1 male and 4 females, with a median age of 51 years (range 29-59 years), developed HT. The median preoperative mRS score was 2 (range 1-4). GTR was achieved in all patients without surgery-related death. BSCM were located in the mesencephalon in 4 patients (80%) who developed HT. Tremor was noticed between ten days and one year after surgery. One patient saw significant improvements to the point of stopping treatment. The median follow-up period was 2 years (range 1-14 years). At the last follow-up, 40% of our patients showed a worse mRS score, 40% stayed unchanged, and 20% improved.

CONCLUSION

We are reporting an original single-center series of patients suffering from HT after BSCM surgery. The risk for HT after surgery is significant for midbrain BSCM. A spontaneous favorable evolution is possible.

Microsurgery vs. Gamma Knife Radiosurgery for the Treatment of Brainstem Cavernous Malformations: A Systematic Review and Meta-Analysis

Background: Brainstem cavernous malformations (BSCMs) are a subset of cerebral cavernous malformations with precarious locations and potentially devastating clinical courses. The effects and outcomes of treating BSCMs by microsurgery or gamma knife radiosurgery (GKRS) vary across studies.

Methods: We searched the Medline, Web of Science, The Cochrane Library, PubMed, and China Biology Medicine disc databases for original articles published in peer-reviewed journals of cohort studies reporting on 20 or more patients of any age with BSCMs with at least 80% completeness of follow-up.

Results: We included 43 cohorts involving 2,492 patients. Both microsurgery (RR = 0.04, 95% CI 0.01–0.16, P < 0.01) and GKRS (RR = 0.11, 95% CI 0.08–0.16, P < 0.01) demonstrated great efficacy in reducing the rehemorrhage rate after treatment for BSCMs. The incidence rates of composite outcomes were 19.8 (95% CI 16.8–22.8) and 15.7 (95% CI 11.7–19.6) after neurosurgery and radiosurgery, respectively. In addition, we found statistically significant differences in the median numbers of patients between neurosurgical and radiosurgical cohorts in terms of symptomatic intracranial hemorrhage (ICH; neurosurgical cohorts: median 0, range 0–33; radiosurgical cohorts: median 4, range 1–14; P < 0.05) and persistent focal neurological deficit (FND; neurosurgical cohorts: median 5, range 0–140; radiosurgical cohorts: median 1, range 0–3; P < 0.05).

Conclusions: The reported effects of treating BSCMs by microsurgery or GKRS are favorable for reducing recurrent hemorrhage from BSCMs. Patients in the neurosurgery cohort had a lower incidence of symptomatic ICH, while patients in the radiosurgical cohort had a lower incidence of persistent FND.

Risk Factors for Poor Postoperative Outcome and Epileptic Symptoms in Patients Diagnosed with Cerebral Cavernous Malformations

BACKGROUND AND STUDY OBJECTIVE

 Roughly 12 to 47% of individuals with cerebral cavernous malformations (CCM) are asymptomatic, while other people may present with symptoms such as epileptic seizures, neurologic deficits, and intracerebral hemorrhages (IH). The aim of this study was to report our experience of postoperative outcomes of patients diagnosed with CCMs.

PATIENTS AND METHODS

 We present a series of consecutive patients who underwent surgical treatment for a diagnosed CCM between January 2003 and March 2014. Data were retrospectively analyzed with respect to preoperative visits, operating reports, patient admission charts, and postoperative follow-up visits. The Engel scale was used to evaluate the outcome of patients with epileptic seizures.

RESULTS

 A total of 91 patients were included with a mean age of 38.8 ± 15 years (range: 2-72 years). Prior to surgery, 57 of these patients had epileptic seizures, while 25 patients recorded at least one episode of IH with a latency time of 6.7 ± 8.5 years (range: 3-240 months) in between hemorrhages. A CCM located within the brainstem was significantly associated with IH prior to surgery (p = 0.000). If the CCM was adjacent to an eloquent brain area, the postoperative outcome in terms of seizure control was significantly worse (p = 0.033). In addition, a trend for worsened outcomes according to the Engel scale was observed in patients with more than one seizure prior to surgery (p = 0.055).

CONCLUSION

 Proximity of CCMs to eloquent brain areas is a risk factor for poor postoperative outcome with respect to a lower rate of medication reduction as well as a lower rate of epileptic seizure omission. This underlines the importance of patient-specific therapeutic approaches.

Application of functional imaging, neuronavigation, and intraoperative MR imaging in the surgical treatment of brain cavernomas

Objective: The aim of this study was to investigate whether preoperative functional imaging and intraoperative magnetic resonance imaging (iMRI) facilitate surgery and improve outcomes in the surgical treatment of cavernous malformations of the brain (CM).Materials and Methods: Retrospective data analysis was performed for consecutive patients diagnosed with a CM who underwent surgical treatment at a single academic institution during a 12 year period. A total of 91 patients was eligible for analysis with a mean age of 38.8 ± 15 years (range 2-72 years). Altogether, 89.0% of CM had supratentorial and 11% infratentorial location.Results: Neuronavigation and iMRI was used in 69 (75.8%) patients with 28 (30.8%) of them together with functional MRI (fMRI) all in the supratentorial location. In 4.3% (3 cases) an intraoperative second-look surgery was performed. Altogether, a complete resection was achieved in 93% of the patients. In supratentorial surgeries, surgical times were significantly shorter in the fMRI group (p = 0.036), but altogether, infratentorial CM surgery took significantly longer (p = 0.014). Moreover, in the fMRI group, reduction of seizure medication was achieved significantly more often (p = 0.026). At an FU of 6.1± 3.1 years, 96% of the patients were assessed modified Rankin Scale 0 or 1.Conclusion: Neuronavigation together with intraoperative and functional MRI had a significant impact on resection amount, surgical time, and neurological and seizure outcome of supratentorial CM. In addition, iMRI was beneficial in few-selected cases.

Retrosigmoid Approach: A Simple and Safe Way to Resect Intrinsic Pontomedullary Lesions

Objectives  The main objective of this article is to describe a simple and safe protocol for the microsurgical management of ventrally located intrinsic pontomedullary lesions based on the retrosigmoid approach, cortectomy performed utilizing safe entry zones of the pons and medulla, and a delicate microsurgical resection. The intraoperative protocol includes redundant procedures that provide security in decision-making during surgery. Design  A prospective series of 11 cases is presented. All patients were studied following the same clinical and imaging workup. A regular retrosigmoid craniotomy surgical approach was utilized. The peritrigeminal area in the pons and the olivary area in the medulla were considered as the safe entry zones. Neuronavigation of the white fiber tracts and electrophysiological monitoring were used as intraoperative aids to locate the lesions, the safe entry zones, and the placement of the cortectomy. Results  Six lesions were pontine, two medullary, and the remaining six pontomedullary. Eight lesions were cavernomas, while the remaining three tumors. Overall, we obtained a postoperative functional improvement in the affected cranial nerves in 90.1% of the patients and a total or partial recovery of long ascending or descending pathway symptoms in 72.3% of the patients. All the patients were satisfied with the procedure and the results. Conclusions  Radical resection of ventral intrinsic pontomedullary lesions displays a high degree of intraoperative reliability, and a good clinical result is possible using simple surgical procedures. The anatomical references are the first element in the decision-making process during surgery.

[«Cavernous angiomas» of the brainstem. Clinical manifestations, diagnosis and treatment results]

Introduction

In the current literature, brainstem hematomas and various types of vascular micromalformations are combined into the one group of diseases under the general name «cavernous angioma» (CA). This approach does not make it possible to accurately determine the indications for surgery and predict postoperative outcomes.

Objective

To analyze our own experience in the diagnosis and treatment of patients with the brainstem CA.

Material and methods

There were 515 patients with CA of the brainstem (surgery - 322, conservative treatment - 193 patients) with a follow-up period of more than 5 years. Follow-up survey implied neurological examination, analysis of Karnofsky score, MRI and CT data.

Results

We identified two main groups of patients after comparison of MRI data, intraoperative findings and biopsy data: group 1 - hematomas (191 patients, 59%), group 2 - CA (131 patients, 41%). Each group was characterized by own clinical and radiological features. Postoperative outcomes depended on the disease. Debridement of hematoma ensured early postoperative improvement in 63% of patients, no changes in 21% of cases and impairment in 16% of patients. Less favorable results were observed in patients with CA and no signs of hemorrhage. Clinical impairment occurred in 73% of cases, improvement - only in 5% of patients. The most significant regression of neurological symptoms in long-term postoperative period was observed in patients with hematomas (92% of patients). These ones noted much better clinical state compared with preoperative condition.

Conclusions

The type of brain lesion is an important predictor to determine treatment approach. Postoperative outcomes differ significantly in patients with the brainstem hematoma and CA.

Brainstem cavernous malformations - no longer a forbidden territory? A systemic review of recent literature

BACKGROUND

Due to its eloquent location and potentially devastating neurological consequences, the management of brainstem cavernous malformations (CCMs) attracts considerable debate. There is currently a paucity of Level 1 evidence for their management. The aim of this literature review is to explore the current evidence on the risk-benefit profile of different management options.

METHODS

A systemic literature search, following the PRISMA algorithm was performed on publications between 2010 and 2018 using the Pubmed database, with the relevant keywords. Only English articles were included. Articles focusing on spinal CCMs and studies with less than 30 participants were excluded.

RESULTS

A total of 222 search results were reviewed and after removal of duplicates and screening of abstracts, 28 clinical papers comprising 30 or more brainstem CCM cases were included in the study. The heterogeneity of the publications precluded a formal meta-analysis of results. The general consensus is that for CCMs presenting with severe symptoms and/or multiple haemorrhages that reach an accessible pial surface, surgery is considered to be the gold-standard treatment, with some authors suggesting the optimal timing to be within two to six weeks of ictus. For those patients with multiple, deep-seated CCM related haemorrhages that do not reach the pial surface, stereotactic radiosurgery (SRS) can be considered. Conservative treatment is generally considered in incidental cases. Management of brainstem cavernomas of other categories still remains controversial.

CONCLUSIONS

Due to their highly eloquent location, brainstem CCMs are challenging lesions to manage. Management must be balanced by the risk-benefit profile and tailored to the individual patients and their treating clinicians. This review provides a comprehensive reference considering all treatment options and provides a basis for evidence-based patient counselling.

A systematic review and meta-analysis of surgeries performed for treating deep-seated cerebral cavernous malformations

OBJECTIVE

The clinical benefit of surgery for treatment of deep-seated cerebral cavernous malformations (CCMs) is still a matter of debate. Although the surgical removal of CCMs is widely accepted, the benefits of reducing the rate of haemorrhage must be balanced against the risk of peri-operative morbidity. Here, we provide a systematic review and meta-analysis of the clinical benefits of surgery for treating deeply localised CCMs.

METHODS

A comprehensive search of PubMed and Embase was conducted to identify relevant studies. The rate and a 95% confidence interval (CI) were used to measure the risk of haemorrhage and adverse outcomes.

RESULTS

A total of 34 cohort studies reporting surgeries on CCMs were included in our analysis. Overall, the average post-surgical haemorrhage rate was 1.0% (95% CI: 0.7-1.4%). Nine per cent (95% CI: 6.9-11.3%) of the patients developed adverse events at follow-up following the surgical resection of deep-seated CCMs. The percentage of transient neural defects following surgical resection was 34.6% (95% CI: 29.4-39.9%). The proportions of transient focal neurological defect before and after the year 2006 were 44.9% (95% CI: 34.1-55.8%) and 30.3% (95% CI: 25.1-35.9%), respectively.

CONCLUSIONS

Our meta-analysis demonstrates post-surgical haemorrhage rate and complications related to surgeries on deep-seated CCMs. The post-surgical haemorrhage rate was low with a relatively high rate of post-surgical complications.