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Tatagiba M, Lepski G, Kullmann M, Krischek B, Danz S, Bornemann A, Klein J, Fahrig A, Velnar T, Feigl GC. The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1601. [PMID: 37763720 PMCID: PMC10537097 DOI: 10.3390/medicina59091601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.
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Affiliation(s)
- Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Guilherme Lepski
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Marcel Kullmann
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Boris Krischek
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Soeren Danz
- Department of Neuroradiology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Antje Bornemann
- Department of Neuropathology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Jan Klein
- Institute for Medical Image Computing, Fraunhofer MEVIS, 28359 Bremen, Germany
| | - Antje Fahrig
- Department of Radiotherapy and Radiooncology, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Guenther C. Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
- Department of Neurosurgery, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
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Lee CC, Wang WH, Yang HC, Lin CJ, Wu HM, Lin YY, Hu YS, Chen CJ, Chen YW, Chou CC, Liu YT, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Hsu SPC. Gamma Knife radiosurgery for cerebral cavernous malformation. Sci Rep 2019; 9:19743. [PMID: 31874979 PMCID: PMC6930272 DOI: 10.1038/s41598-019-56119-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022] Open
Abstract
This is a retrospective study examining the efficacy and safety of Gamma Knife radiosurgery (GKS) in treating patients with cerebral cavernous malformations (CCMs). Between 1993 and 2018, 261 patients with 331 symptomatic CCMs were treated by GKS. The median age was 39.9 years and females were predominant (54%). The median volume of CCMs was 3.1 mL. The median margin dose was 11.9 Gy treat to a median isodose level of 59%. Median clinical and imaging follow-up times were 69 and 61 months, respectively. After the initial hemorrhage that led to CCM diagnosis, 136 hemorrhages occurred in the period prior to GKS (annual incidence = 23.6%). After GKS, 15 symptomatic hemorrhages occurred within the first 2 years of follow-up (annual incidence = 3.22%), and 37 symptomatic hemorrhages occurred after the first 2 years of follow-up (annual incidence = 3.16%). Symptomatic radiation-induced complication was encountered in 8 patients (3.1%). Mortality related to GKS occurred in 1 patient (0.4%). In conclusion, GKS decreased the risk of hemorrhage in CCM patients presenting with symptomatic hemorrhage. GKS is a viable alternative treatment option for patients with surgically-inaccessible CCMs or significant medical comorbidities.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsin Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Chen Chou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yo-Tsen Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sanford P C Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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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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Chen L, Zhao Y, Zhou L, Zhu W, Pan Z, Mao Y. Surgical strategies in treating brainstem cavernous malformations. Neurosurgery 2011; 68:609-20; discussion 620-1. [PMID: 21164376 DOI: 10.1227/neu.0b013e3182077531] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimal therapy of brainstem cavernous malformations (BSCMs) remains controversial because their biological behavior is unpredictable and surgical removal is challenging. OBJECTIVE To analyze our experience with BSCMs and to conduct a review of the literature to identify a rational approach to the management of these lesions. METHODS Fifty-five patients harboring 57 BSCMs underwent surgery and 17 patients were treated conservatively during the 10-year period from 1999 to 2008. The operative strategy was to perform complete CM resection and to preserve any associated venous malformation with minimal functional brainstem tissue sacrificed. The National Institutes of Health Strength Scale (NIHSS) was used to assess neurological status. RESULTS The average hemorrhagic and rehemorrhagic rates were 4.7% and 32.7% per patient-year, respectively. Total lesional resection was achieved in all operated patients. Their mean NIHSS score was 4.6 after the first episode, 3.5 preoperatively, 3.2 at discharge, and 1.4 after a mean follow-up of 49 months. Complete recovery rates of motor deficits and sensory disturbances from the preoperative state were 70.4% and 51.7%, respectively. Complete recovery rates for cranial nerves III, V, VI, and VII and the lower group were 60%, 63.2%, 25%, 57.1%, and 80%, respectively. For the conservative patients, the mean NIHSS score was 5.9 after the first episode and 1.7 after a mean follow-up of 40 months. CONCLUSION NIHSS is optimal for evaluating the natural history and surgical effect of patients harboring BSCMs. Surgical resection remains the primary therapeutic option after careful patient screening and preoperative planning.
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Affiliation(s)
- Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai Neurosurgical Clinical Center, Shanghai, China
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Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. ACTA ACUST UNITED AC 2009; 72 Suppl 2:S3-9; discussion S9-10. [PMID: 19665186 DOI: 10.1016/j.surneu.2009.05.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 05/27/2009] [Indexed: 01/01/2023]
Abstract
BACKGROUND The contemporary neurosurgeon is often confronted by cavernous malformations. Those located in the brainstem are particularly challenging METHODS This article reviews published series on the natural history and surgical outcomes of these lesions and discusses the surgical approaches used at our institution for their resection. RESULTS Despite their challenging location in the brainstem, appropriately selected lesions can be resected surgically with acceptable rates of morbidity and mortality. CONCLUSIONS Our institutional philosophy on the surgical treatment of brainstem cavernous malformations reflects the substantial surgical experience of the senior author.
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Affiliation(s)
- Mark Garrett
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Gross BA, Batjer HH, Awad IA, Bendok BR. BRAINSTEM CAVERNOUS MALFORMATIONS. Neurosurgery 2009; 64:E805-18; discussion E818. [DOI: 10.1227/01.neu.0000343668.44288.18] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bradley A. Gross
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Issam A. Awad
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Bernard R. Bendok
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
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Cenzato M, Stefini R, Ambrosi C, Giovanelli M. Post-operative remnants of brainstem cavernomas: incidence, risk factors and management. Acta Neurochir (Wien) 2008; 150:879-86; discussion 887. [PMID: 18754072 DOI: 10.1007/s00701-008-0008-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 05/30/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The risk of leaving a remnant after surgery for a cavernous malformation in the brainstem is generally not stressed enough, even though such remnants appear to have a high risk of re-bleeding. At least 40% of known cavernoma remnants after surgery have further bleeding episodes. A retrospective analysis of 30 patients with brainstem cavernoma who underwent surgery is presented, focusing on incidence, risk factors and management of post-surgical residuals. The sites were, medulla in three patients, pons-medulla in four, pons in 16, pons-midbrain in four and midbrain in three. All 30 patients came to our clinical observation with at least one episode of acute-onset neurological deficit and all were operated in the sub-acute phase. Only one patient had a worse stable outcome than the pre-surgical state, and 29 did better or were stable. All patients had a brain MRI scan within 72 h after surgery to confirm that complete removal had been achieved. In three, although the surgical cavity and its border appeared clean at the end of surgery, with no lesion remaining, post-operative MRI detected a residuum. These three patients were re-operated, but one had a further bleed prior to excision. MATERIALS AND METHODS In our series, the surgical finding of a multi-lobular cavernoma (as opposed to the more frequent finding of a discrete lesion with a thick capsule), with a thin wall and satellite nodules separated by a thin layer of apparently intact white matter, was common (seven patients). This group included the three patients with evidence of residuum on post-operative MRI. In our experience, the surgical finding of a multi-lobular cavernoma carries a higher risk of residuum and post-surgical re-bleeding. CONCLUSION Immediate post-operative brain MRI scans are therefore strongly recommended for their detection, especially in this group of patients, and if a residual is detected early re-intervention is less risky than the natural history.
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