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Catapano JS, Koester SW, Rumalla K, Lamorie-Foote K, Winkler EA, Benner D, Scherschinski L, Baranoski JF, Cole TS, Rudy RF, Graffeo CS, Srinivasan VM, Spetzler RF, Lawton MT. Microsurgical Resection of Brainstem Cavernous Malformations in Older Adults: A Multicenter, 30-Year Experience. Neurosurgery 2024; 95:669-675. [PMID: 38551352 DOI: 10.1227/neu.0000000000002928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/30/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Microsurgical resection is the only curative intervention for symptomatic brainstem cavernous malformations (BSCMs), but the management of these lesions in older adults (≥65 years) is not well described. This study sought to address this gap by examining the safety and efficacy of BSCM resection in a cohort of older adults. METHODS Records of patients who underwent BSCM resection over a 30-year period were reviewed retrospectively. Baseline characteristics and outcomes were compared between older (≥65 years) and younger (<65 years) patients. RESULTS Of 550 patients with BSCM who met inclusion criteria, 41 (7.5%) were older than 65 years. Midbrain (43.9% vs 26.1%) and medullary lesions (19.5% vs 13.6%) were more common in the older cohort than in the younger cohort ( P = .01). Components of the Lawton BSCM grading system (ie, lesion size, crossing axial midpoint, developmental venous anomaly, and timing of hemorrhage) were not significantly different between cohorts ( P ≥ .11). Mean (SD) Elixhauser comorbidity score was significantly higher in older patients (1.86 [1.06]) than in younger patients (0.66 [0.95]; P < .001). Older patients were significantly more likely than younger patients to have poor outcomes at final follow-up (28.9% vs 13.8%, P = .01; mean follow-up duration, 28.7 [39.1] months). However, regarding relative neurological outcome (preoperative modified Rankin Scale to final modified Rankin Scale), rate of worsening was not significantly different between older and younger patients (23.7% vs 14.9%, P = .15). CONCLUSION BSCMs can be safely resected in older patients, and when each patient's unique health status and life expectancy are taken into account, these patients can have outcomes similar to younger patients.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Krista Lamorie-Foote
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles , California , USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Zhou J, Wang R, Mao J, Gu Y, Shao A, Liu F, Zhang J. Prognostic models for survival and consciousness in patients with primary brainstem hemorrhage. Front Neurol 2023; 14:1126585. [PMID: 36908614 PMCID: PMC9995821 DOI: 10.3389/fneur.2023.1126585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Primary brainstem hemorrhage (PBSH) is one of the most catastrophic spontaneous intracerebral hemorrhage diseases, with a mortality rate of 70-80%. We explored the predictive factors for survival and consciousness in patients with PBSH (ClinicalTrials.gov ID: NCT04910490). Methods We retrospectively reviewed 211 patients with PBSH admitted to our institution between January 2014 and October 2020. Clinical outcomes included the 30-day survival rate and the 90-day consciousness rate as evaluated by the National Institutes of Health Stroke Scale score. Multiple logistic regression analysis was performed. Results The overall 30-day survival rate of 211 patients with PBSH was 70%. Several predictive factors including hematoma volume, hematoma location, activated partial thromboplastin time (APTT) upon admission, and therapeutic strategy were significantly related to 30-day survival. Compared with conservative treatment, stereotactic aspiration in our prediction model is strongly associated with improved 30-day survival (odds ratio, 6.67; 95% confidence interval, 3.13-14.29; P < 0.001). The prognosis prediction model of 90-day consciousness including factors such as mydriasis, APTT value, hematoma location, and hematoma volume upon admission has a good predictive effect (AUC, 0.835; 95% confidence interval, 0.78-0.89; P < 0.001). Conclusion In patients with PBSH, conscious state upon admission, coagulation function, hematoma volume, hematoma location, and therapeutic strategy were significantly associated with prognosis. Stereotactic aspiration could significantly reduce the 30-day mortality rate.
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Affiliation(s)
- Jingyi Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Rui Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jizhong Mao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, Zhejiang, China
| | - Yichen Gu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fengqiang Liu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Brain Research Institute, Zhejiang University, Hangzhou, Zhejiang, China
- Collaborative Innovation Center for Brain Science, Zhejiang University, Hangzhou, Zhejiang, China
- Stroke Research Center for Diagnostic and Therapeutic Technologies of Zhejiang Province, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
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3
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Catapano JS, Rutledge C, Rumalla K, Raygor KP, Srinivasan VM, Koester SW, Kimata AR, Ma KL, Labib MA, Spetzler RF, Lawton MT. External validation of the Lawton brainstem cavernous malformation grading system in a cohort of 277 microsurgical patients. J Neurosurg 2022; 136:1231-1239. [PMID: 34598133 DOI: 10.3171/2021.3.jns204291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The brainstem cavernous malformation (BSCM) grading system predicts neurological outcomes associated with microsurgical resection and assists neurosurgeons in selecting patients for treatment. The predictive accuracy of the BSCM grading system should be validated in a large cohort from high-volume centers to generalize its use. METHODS An external validation cohort comprised patients with a BSCM resected by the senior author (M.T.L.) since the publication of the BSCM grading system and those resected by another neurosurgeon (R.F.S.) over a 16-year period. Size, crossing the axial midpoint, the presence of a developmental venous anomaly, patient age, and timing of last hemorrhage were used to assign BSCM grades from 0 to VII. Poor neurological outcomes were recorded as modified Rankin Scale scores > 2 at last follow-up examination. RESULTS A total of 277 patients were included in the study. The average BSCM grade was 3.9, and the majority of BSCMs (181 patients, 65%) were intermediate grade (grades III-V). Outcomes were predicted by BSCM grade, with good outcomes observed in 47 of 54 patients (87%) with low-grade BSCMs, in 135 of 181 patients (75%) with intermediate-grade BSCMs, and in 21 of 42 patients (50%) with high-grade BSCMs. Conversely, proportions of patients with neurological deterioration increased with increasing BSCM grade, with worsening observed in 2 of 54 patients (4%) with low-grade BSCMs, in 29 of 181 patients (16%) with intermediate-grade BSCMs, and in 17 of 42 patients (40%) with high-grade BSCMs. In the chi-square analysis, high-grade BSCMs were associated with increased odds of neurological worsening compared to low- and intermediate-grade BSCMs (OR 5.0, 95% CI 2.4-10.4; p < 0.001). The receiver operating characteristic analysis demonstrated acceptable discrimination for predicting unfavorable functional outcomes (modified Rankin Scale score > 2) with an area under the curve of 0.74 (95% CI 0.68-0.80; p < 0.001). CONCLUSIONS This study validates the BSCM grading system in a large cohort of patients from two high-volume surgeons. BSCM grade predicted neurological outcomes with accuracy comparable to that of other grading systems in widespread use. The BSCM grading system establishes categories of low-, intermediate-, and high-grade BSCMs and a boundary or cutoff for surgery at BSCM grade V. BSCM grading guides the analysis of a particular patient's condition, but treatment recommendations must be individualized, and neurosurgeons must calibrate BSCM grading to their own outcome results, unique abilities, and practices.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Caleb Rutledge
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kavelin Rumalla
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kunal P Raygor
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Stefan W Koester
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Anna R Kimata
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kevin L Ma
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Tomasi SO, Umana GE, Scalia G, Rubio-Rodriguez RL, Raudino G, Rechberger J, Geiger P, Chaurasia B, Yaǧmurlu K, Lawton MT, Winkler PA. Perforating Arteries of the Lemniscal Trigone: A Microsurgical Neuroanatomic Description. Front Neuroanat 2021; 15:675313. [PMID: 34512277 PMCID: PMC8427497 DOI: 10.3389/fnana.2021.675313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The perforating arteries in the dorsolateral zone of the midbrain play a crucial role in the functions of the brain stem. Their damage due to herniation, pathological lesions, or surgery, favored by the narrow tentorial incisura, can lead to hemorrhages or ischemia and subsequently to severe consequences for the patient. Objective: In literature, not much attention has been directed to the perforating arteries in the lemniscus; in fact, no reports on the perforators of this anatomical region are available. The present study aims to a detailed analysis of the microanatomy and the clinical implications of these perforators, in relation to the parent vessels. We focused on the small vessels that penetrate the midbrain's dorsolateral surface, known as lemniscal trigone, to understand better their microanatomy and their functional importance in the clinical practice during the microsurgical approach to this area. Methods: Eighty-seven alcohol-fixed cadaveric hemispheres (44 brains) without any pathological lesions provided the material for studying the perforating vessels and their origin around the dorsolateral midbrain using an operating microscope (OPMI 1 FC, Zeiss). Measurements of the perforators' distances, in relation to the parent vessels, were taken using a digital caliper. Results: An origin from the SCA could be found in 70.11% (61) and from the PCA in 27.58% (24) of the hemispheres. In one hemisphere, an origin from the posterior choroidal artery was found (4.54%). No perforating branches were discovered in 8.04% of specimens (7). Conclusion: The perforating arteries of the lemniscal trigone stem not only from the superior cerebellar artery (SCA), as described in the few studies available in literature, but also from the posterior cerebral artery (PCA). Therefore, special attention should be paid during surgery to spare those vessels and associated perforators. A comprehensive understanding of the lemniscal trigone's perforating arteries is vital to avoid infarction of the brainstem when treating midbrain tumors or vascular malformations.
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Affiliation(s)
- Santino Ottavio Tomasi
- Department of Neurological Surgery - Christian Doppler Klinik, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
- Laboratory for Microsurgical Neuroanatomy - Christian Doppler Klinik, Salzburg, Austria
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
| | - Roberto Luis Rubio-Rodriguez
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Giuseppe Raudino
- Department of Neurosurgery - Humanitas, Istituto Clinico Catanese, Catania, Italy
| | - Julian Rechberger
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Philipp Geiger
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Kaan Yaǧmurlu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, United States
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Peter A. Winkler
- Department of Neurological Surgery - Christian Doppler Klinik, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
- Laboratory for Microsurgical Neuroanatomy - Christian Doppler Klinik, Salzburg, Austria
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Yuen J, Whitfield PC. Brainstem cavernous malformations - no longer a forbidden territory? A systemic review of recent literature. Neurochirurgie 2020; 66:116-126. [PMID: 32112802 DOI: 10.1016/j.neuchi.2019.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/21/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- J Yuen
- South West Neurosurgery Centre, Derriford Hospital, Plymouth Devon, UK PL6 8DH.
| | - P C Whitfield
- South West Neurosurgery Centre, Derriford Hospital, Plymouth Devon, UK PL6 8DH
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Karadag A, Senoglu M, Middlebrooks EH, Kinali B, Guvencer M, Icke C, Sayhan S, Karabay N, Camlar M, Olomu OU, Tanriover N. Endoscopic endonasal transclival approach to the ventral brainstem: Radiologic, anatomic feasibility and nuances, surgical limitations and future directions. J Clin Neurosci 2020; 73:264-279. [PMID: 32005412 DOI: 10.1016/j.jocn.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/04/2020] [Indexed: 12/25/2022]
Abstract
The endoscopic endonasal transclival approach (EETA) is less invasive than traditional open approaches; however, there is currently limited data on the pre-operative features that may predict success of the EETA. Surgical landmarks and exposure of the EETA and expanded EETA are assessed. We retrospectively measured multiple anatomic features in 154 adult dry skulls, 22 C1 and C2 dry bone vertebrae, and 500 paranasal sinus computed tomography (CT) scans. We also dissected 13 formalin-fixed, silicone-injected adult cadaveric heads. Relevant qualitative and quantitative data were obtained with CT (n = 10) and cadaveric dissection (n = 13). They are expressed as mean (SD), as appropriate and compared with unpaired t tests. Categorical variables were compared with χ2 tests. We determined the prevalence of clival and sphenoid sinus anatomic variations and assessed potential exposure of the craniovertebral region, based on the relative position of the nasal bone tip, posterior point of the hard palate, and their relation to the position of C1 and C2. Depending on anatomic features, EETA should allow visualization of the ventral brainstem. The mean (SD) dimensions of the surgical window for EETA were 43.2 (5.1) × 18.3 (1.1) mm, in the craniocaudad and horizontal dimensions, respectively. The craniocaudad dimension enlarged to 60.2 (4.7) mm with expanded EETA. The EETA allowed satisfactory exposure for odontoid and C1 anterior arch resection (expanded EETA) in all specimens, regardless of the orientation of the palate. The combination of preoperative radiographic assessment and intraoperative considerations allows safe and effective application and facilitate selection of the most appropriate approach.
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Affiliation(s)
- Ali Karadag
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mehmet Senoglu
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey.
| | - Erik H Middlebrooks
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Burak Kinali
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mustafa Guvencer
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Cigdem Icke
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Salih Sayhan
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Nuri Karabay
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mahmut Camlar
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Osarenoma U Olomu
- Department of Otorhinolaryngology/Audiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Kearns KN, Chen CJ, Tvrdik P, Park MS, Kalani MYS. Outcomes of Surgery for Brainstem Cavernous Malformations. Stroke 2019; 50:2964-2966. [DOI: 10.1161/strokeaha.119.026120] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The goal of this study was to systematically review the outcomes and complications after surgical resection of brain stem cavernous malformations (BCMs).
Methods—
A systematic literature review was performed using the PubMed database for studies published between 1986 and 2018. All studies comprising ≥2 patients with surgically resected BCMs and available follow-up data were included. Data extracted from studies included patient demographics, BCM location, and surgical outcomes.
Results—
Eighty-six studies comprising 2493 patients (adult and pediatric) were included for final analysis. Complete resection was achieved in 92.3% (fixed-effects pooled estimate [FE], 92.9% [91.7%–94.0%]; random-effects pooled estimate [RE], 89.4% [86.5%–92.0%]) of patients, and rehemorrhage of residual BCMs occurred in 58.6% (FE, 58.8% [49.7%–67.6%]; RE, 57.2% [43.5%–70.2%]). Postoperative morbidity occurred in 34.8% (FE, 30.9% [29.0%–32.8%]; RE, 31.1% [25.8%–36.6%]) of patients. Postoperative morbidities included motor deficit in 11.0% (FE, 9.9% [8.1%–11.7%]; RE, 11.1% [7.0%–16.0%]), sensory deficit in 6.7% (FE, 6.3% [4.8%–7.9%]; RE, 7.6% [4.5%–11.5%]), tracheostomy/gastrostomy in 6.0% (FE, 5.2% [4.3%–6.1%]; RE, 3.8% [2.6%–5.3%]), and other cranial nerve deficits in 29.4% (FE, 27.6% [25.3%–29.9%]; RE, 33.9% [25.7%–42.6%]) of patients. At final follow-up, 57.9% (FE, 57.6% [55.6%–59.6%]; RE, 57.2% [52.1%–62.3%]) and 25.9% (FE, 24.1% [22.4%–25.9%]; RE, 18.5% [14.6%–22.8%]) of patients had improvement and stability of preoperative symptoms, respectively. Mortality rate was 1.6% (FE, 1.9% [1.4%–2.5%]; RE, 1.8% [1.4%–2.5%]).
Conclusions—
High cure rates and low rates of postoperative morbidity can be achieved with surgery in patients with BCMs. Most patients had improved preoperative symptoms at final follow-up. To avoid rehemorrhage, complete resection should be the goal of surgery.
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Affiliation(s)
- Kathryn N. Kearns
- From the Department of Neurological Surgery, University of Virginia Health System, Charlottesville
| | - Ching-Jen Chen
- From the Department of Neurological Surgery, University of Virginia Health System, Charlottesville
| | - Petr Tvrdik
- From the Department of Neurological Surgery, University of Virginia Health System, Charlottesville
| | - Min S. Park
- From the Department of Neurological Surgery, University of Virginia Health System, Charlottesville
| | - M. Yashar S. Kalani
- From the Department of Neurological Surgery, University of Virginia Health System, Charlottesville
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Surgical Management of Brainstem Cavernous Malformation: Report of 67 Patients. World Neurosurg 2019; 122:e1162-e1171. [DOI: 10.1016/j.wneu.2018.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
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9
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Rajagopal N, Kawase T, Mohammad AA, Seng LB, Yamada Y, Kato Y. Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature. Asian J Neurosurg 2019; 14:15-27. [PMID: 30937003 PMCID: PMC6417313 DOI: 10.4103/ajns.ajns_158_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.
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Affiliation(s)
- Niranjana Rajagopal
- Department of Neurosurgery, Sathya Sai Institute of Higher Medical Science, Bengaluru, Karnataka, India
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | | | - Liew Boon Seng
- Department of Neurosurgery, Sungai Buloh Hospital, Selangor, Malaysia
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Cavalcanti DD, Morais BA, Figueiredo EG, Spetzler RF, Preul MC. Supracerebellar Infratentorial Variant Approaches to the Intercollicular Safe Entry Zone. World Neurosurg 2018; 122:e1285-e1290. [PMID: 30447444 DOI: 10.1016/j.wneu.2018.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe and compare surgical exposure through microsurgical cadaveric dissection of the intercollicular region afforded by the median, paramedian, and extreme-lateral supracerebellar infratentorial (SCIT) approaches. METHODS Ten cadaveric heads were dissected using SCIT variant approaches. A neuronavigation system was used to determine tridimensional coordinates for the intercollicular zone in each route. The areas of surgical and angular exposure were evaluated and determined by software analysis for each specimen. RESULTS The median surgical exposure was similar for the different craniotomies: 282.9 ± 72.4 mm2 for the median, 341.2 ± 71.2 mm2 for the paramedian, and 312.0 ± 79.3 mm2 for the extreme-lateral (P = 0.33). The vertical angular exposure to the center of the intercollicular safe entry zone was also similar between the approaches (P = 0.92). On the other hand, the horizontal angular exposure was significantly wider for the median approach (P < 0.001). CONCLUSIONS All the SCIT approaches warrant a safe route to the quadrigeminal plate. Among the different variants, the median approach had the smallest median surgical area exposure but presented superior results to access the intercollicular safe entry zone.
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Affiliation(s)
- Daniel Dutra Cavalcanti
- Department of Neurological Surgery, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | | | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Xie MG, Xiao XR, Guo FZ, Zhang JT, Wu Z, Zhang LW. Surgical Management and Functional Outcomes of Cavernous Malformations Involving the Medulla Oblongata. World Neurosurg 2018; 119:e643-e652. [PMID: 30077748 DOI: 10.1016/j.wneu.2018.07.229] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical features, surgical complications, and functional outcomes of the surgical treatment of patients with cavernous malformations (CMs) involving the medulla oblongata. METHODS The charts of 69 patients undergoing surgical treatment of CMs in the medulla oblongata, pontomedullary, and cervicomedullary junctions between 2011 and 2017 were retrospectively reviewed. Patient demographics, lesion characteristics, operative documents, and patient outcomes were examined. RESULTS Of the 69 patients, the male-to-female ratio was 1.3. The mean patient age was 32.6 years, and the mean mRS score was 2.7 on admission. Postoperatively, 21 patients (30.4%) had deficits of cough reflexes, and 6 patients (8.7%) experienced respiratory rhythm disorder and dyspnea. The mean follow-up duration was 35.3 months. At the last follow-up evaluation, the mean mRS score was 1.8, and 53 patients (80.3%) had favorable outcomes, with mRS scores ≤2. The conditions of the patients improved in 45 cases (68.2%), remained unchanged in 11 cases (16.7%), and worsened in 10 cases (15.1%) relative to their preoperative baseline. The independent adverse factors for long-term functional outcome were increased age, multiple hemorrhages, presence of developmental venous anomalies, and lack of perilesional edema. CONCLUSIONS Respiratory dysfunction and deficits of cough reflexes can commonly occur during the early postoperative period for surgical resection of CMs involving the medulla oblongata. Favorable functional outcomes can be achieved by surgery, especially for younger patients who experience fewer hemorrhages and have lesions with perilesional edema and the absence of developmental venous anomalies.
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Affiliation(s)
- Ming-Guo Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xin-Ru Xiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Fang-Zhou Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.
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12
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Symptomatic Brainstem Cavernoma of Elderly Patients: Timing and Strategy of Surgical Treatment. Two Case Reports and Review of the Literature. World Neurosurg 2018; 111:227-234. [DOI: 10.1016/j.wneu.2017.12.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/16/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022]
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13
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Xie MG, Li D, Guo FZ, Zhang LW, Zhang JT, Wu Z, Meng GL, Xiao XR. Brainstem Cavernous Malformations: Surgical Indications Based on Natural History and Surgical Outcomes. World Neurosurg 2018; 110:55-63. [DOI: 10.1016/j.wneu.2017.10.121] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 11/17/2022]
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14
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Risk Factors for Unfavorable Outcomes in Surgically Treated Brainstem Cavernous Malformations. World Neurosurg 2017; 111:e478-e484. [PMID: 29288109 DOI: 10.1016/j.wneu.2017.12.105] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/15/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) account for up to 18% of all intracranial cavernous malformations. Due to their complex anatomic location, they represent a significant challenge for neurosurgeons. As such, the identification of risk factors associated with negative outcomes is of significant importance. We analyze a series of 50 cases of BSCMs treated surgically in order to identify risk factors for unfavorable outcomes. METHODS Patients who underwent surgical resection of BSCM at our institution between 2000 and 2015 were retrospectively reviewed. Univariate and multivariable logistic regression models were used to identify predictors of unfavorable outcomes, defined as those with a modified Rankin score (mRs) of >2. RESULTS Fifty Latin American patients, with a mean age of 35.85 ± 13.06 years, consisting of 29 females (58%) and 21 males (42%), underwent surgical resection. Mean modified Rankin Scale (mRs) score at admission was 2.6 ± 1.05, and the mean BCSM size was 18.00 ± 7.19 mm. The rate of gross total resection was 92%. Overall, 80% of patients showed improved or unchanged clinical status at the last follow-up period; however, only 58% of patients had a favorable outcome with a mean mRs of 2.33 ± 1.136. Multivariable logistic binary regression identified hemorrhagic recurrence (P = 0.040), lower cranial nerve deficit (P = 0.019), and BSCMs >15 mm in diameter (P = 0.006) as predictive factors for unfavorable surgical outcomes. CONCLUSION BSCM size, compromise of lower cranial nerves, and hemorrhagic recurrence before surgery were identified as risk factors associated with unfavorable outcomes of surgically treated BSCMs in this cohort.
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Tumturk A, Li Y, Turan Y, Cikla U, Iskandar BJ, Baskaya MK. Emergency resection of brainstem cavernous malformations. J Neurosurg 2017; 128:1289-1296. [PMID: 28686112 DOI: 10.3171/2017.1.jns161693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors' knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neurological deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs.
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Ghali MGZ, Srinivasan VM, Mohan AC, Jones JY, Kan PT, Lam S. Pediatric cerebral cavernous malformations: Genetics, pathogenesis, and management. Surg Neurol Int 2016; 7:S1127-S1134. [PMID: 28194299 PMCID: PMC5299150 DOI: 10.4103/2152-7806.196921] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/14/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Michael G Z Ghali
- Department of Neurobiology, Drexel University College of Medicine, Philadelphia, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Arvind C Mohan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jeremy Y Jones
- Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Peter T Kan
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Tsuji K, Nitta N, Takagi K, Yokoi T, Nozaki K. Two cases of ventral midbrain cavernous malformations successfully removed through orbitozygomatic interpeduncular approach. INTERDISCIPLINARY NEUROSURGERY 2016. [DOI: 10.1016/j.inat.2016.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cavalcanti DD, Preul MC, Kalani MYS, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg 2016; 124:1359-76. [DOI: 10.3171/2015.4.jns141945] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECT
The aim of this study was to enhance the planning and use of microsurgical resection techniques for intrinsic brainstem lesions by better defining anatomical safe entry zones.
METHODS
Five cadaveric heads were dissected using 10 surgical approaches per head. Stepwise dissections focused on the actual areas of brainstem surface that were exposed through each approach and an analysis of the structures found, as well as which safe entry zones were accessible via each of the 10 surgical windows.
RESULTS
Thirteen safe entry zones have been reported and validated for approaching lesions in the brainstem, including the anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region, peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicularzone, infracollicularzone, median sulcus of the fourth ventricle, anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone. A discussion of the approaches, anatomy, and limitations of these entry zones is included.
CONCLUSIONS
A detailed understanding of the anatomy, area of exposure, and safe entry zones for each major approach allows for improved surgical planning and dissemination of the techniques required to successfully resect intrinsic brainstem lesions.
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Affiliation(s)
- Daniel D. Cavalcanti
- 1Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; and
| | - Mark C. Preul
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - M. Yashar S. Kalani
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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Electromagnetic navigation-guided surgery in the semi-sitting position for posterior fossa tumours: a safety and feasibility study. Acta Neurochir (Wien) 2015; 157:1229-37. [PMID: 25990847 DOI: 10.1007/s00701-015-2452-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Electromagnetic (EM)-guided neuronavigation is an innovative technique and a viable alternative to opto-electric navigation. We have performed a safety and feasibility study using EM-guided neuronavigation for posterior fossa surgery in the semi-sitting position in a selected subset of patients. METHODS Out of 284 patients with posterior fossa tumours operated upon over a period of 40 months, a subset of 15 patients was thought to possibly benefit from EM navigational guidance and was included in this study. There were six children and nine adults (aged between 8 and 84 years; mean age, 34.6 years) with different neoplasms in the brainstem or close to the midline. All patients had contrast-enhanced three-dimensional (3D) magnetic resonance imaging (MRI) of the head preoperatively. EM-guided navigation was used to identify and preserve the venous sinuses during craniotomy and to determine the trajectory to the lesion using various approaches. Neuronavigation accuracy was repeatedly checked for deviations measured in millimetres on screen shots during surgery before and after dural opening in the coronal (z = vertical), axial (x = mediolateral) and sagittal (y = anteroposterior) plane. RESULTS Referencing of the patient in the supine position was fast and easy. There was no loss of navigation accuracy after repositioning of the patient in the semi-sitting position (mean, 2.5 mm ± 0.92 mm). Identification of the pathological structure using EM navigation was achieved in all instances. Optimal angulation of the neck was selected individually to permit a comfortable position for the surgeon with full access to the lesion avoiding over-flexion. Deviation of accuracy at the surface of the target lesion ranged between 2.5 and 5.8 mm (mean, 3.9 mm ± 1.1 mm). CONCLUSIONS EM-guided neuronavigation in the semi-sitting position was safe and technically feasible. It enabled fast and accurate referencing without loss of navigation accuracy despite repositioning of the patient. In contrast to conventional opto-electric neuronavigation there were no line of sight problems.
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Qiao N, Ma Z, Song J, Wang Y, Shou X, Zhang X, Shen M, Qiu H, Ye Z, He W, Li S, Fu C, Zhao Y. A systematic review and meta-analysis of surgeries performed for treating deep-seated cerebral cavernous malformations. Br J Neurosurg 2015; 29:493-9. [PMID: 25813882 DOI: 10.3109/02688697.2015.1023773] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Nidan Qiao
- a Department of Neurosurgery , HuaShan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
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Lu XY, Sun H, Xu JG, Li QY. Stereotactic radiosurgery of brainstem cavernous malformations: a systematic review and meta-analysis. J Neurosurg 2014; 120:982-7. [PMID: 24506243 DOI: 10.3171/2013.12.jns13990] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Over the last two decades, stereotactic radiosurgery (SRS) has arisen as a promising approach in the management of brainstem cavernous malformations (CMs). In the present study, the authors report a systematic review and meta-analysis of the available published data regarding the radiosurgical management of brainstem CMs. METHODS To identify eligible studies, systematic searches for brainstem CMs treated with SRS were conducted in major scientific publication databases. The search yielded 5 studies, which were included in the meta-analysis. Data from 178 patients with brainstem CMs were extracted. Hemorrhage rates before and after SRS were calculated, a meta-analysis was performed, and the risk ratio (RR) was determined. RESULTS Four studies showed a statically significant reduction in the annual hemorrhage rate after SRS. The overall RR was 0.161 (95% CI 0.052-0.493; p = 0.001), and 21 patients (11.8%) had transient or permanent neurological deficits. CONCLUSIONS The present meta-analysis for the radiosurgical management of brainstem CMs shows that SRS can decrease the rate of repeat hemorrhage and has a low rate of adverse effects compared with surgery. The authors suggest that SRS may be considered as an alternative treatment for brainstem CMs that are inoperable or have a high operative risk.
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Affiliation(s)
- Xin-Yu Lu
- Department of Neurosurgery, People's Hospital Affiliated to Jiangsu University, Zhenjiang
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Prediction of outcomes for brainstem cavernous malformation. Clin Neurol Neurosurg 2013; 115:2117-23. [DOI: 10.1016/j.clineuro.2013.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 06/29/2013] [Accepted: 07/28/2013] [Indexed: 11/18/2022]
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Li D, Yang Y, Hao SY, Wang L, Tang J, Xiao XR, Zhou H, Jia GJ, Wu Z, Zhang LW, Zhang JT. Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations. J Neurosurg 2013; 119:996-1008. [PMID: 23952884 DOI: 10.3171/2013.7.jns13462] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up. METHODS The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined. RESULTS The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter. CONCLUSIONS Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.
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Affiliation(s)
- Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
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Brainstem Cavernous Malformations: 1390 Surgical Cases from the Literature. World Neurosurg 2013; 80:89-93. [DOI: 10.1016/j.wneu.2012.04.002] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/03/2012] [Indexed: 11/23/2022]
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Sabatino G, Rigante L, Marchese E, Albanese A, Esposito G, Capone G, Maira G. Anterior subtemporal approach for posterolateral brainstem cavernomas: report of ten cases. Acta Neurochir (Wien) 2012; 154:2009-16. [PMID: 22961242 DOI: 10.1007/s00701-012-1496-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The neuronavigation-assisted anterior subtemporal approach is proposed in this article as an alternative to surgery of posterolateral brainstem cavernomas. Brainstem cavernomas represent a neurosurgical challenge because of the high morbidity and mortality rate related to their surgical removal. Several nerve nuclei, ascending and descending fibers make this region at high risk of serious postoperative deficits. METHODS Between 1998 and 2010, 24 patients underwent surgical removal of brainstem cavernomas in our institution. Ten of these patients presented a cavernous malformation in the posterolateral region of the brainstem and underwent surgical removal by means of a neuronavigation-assisted anterior subtemporal approach. RESULTS Lesion removal was complete for all patients. There were no cases of surgery-related death. Neurological status improved or remained unchanged after surgery in all cases. All patients presented good outcomes at 12 to 154 months' follow-up (mean 70 months; GOS = 5 in 8/10 patients, 4 in 2/10 patients; mRS = 0-1 in all patients). Only one patient presented transient confusion, aphasia and seizures related to temporal lobe swelling, which resolved completely within a few days. One patient developed cranial nerve III palsy and left hemiparesis with gradual recovery. CONCLUSIONS This approach represents a valid alternative to the "more classical" approaches for the surgery of posterolateral cavernomas of the pontomesenchephalic junction reaching the tentorial incisura, reducing the risk of damaging the vein of Labbé, temporal lobe swelling, cerebellar swelling, ophtalmoparesis, fourth ventricle cranial nerve nuclei lesions. Skeletonization of sigmoidal sinus provides with good outcomes, low morbidity and mortality.
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