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

Management of recurrent lumbar disc herniation: a comparative analysis of posterior lumbar interbody fusion and repeat discectomy

Background

For recurrent lumbar disc herniation, many experts suggest a repeat discectomy without stabilization due to its minimal tissue manipulation, lower blood loss, shorter hospital stay, and lower cost, recent research on the role of instability in disc herniation has made fusion techniques popular among spinal surgeons. The authors compare the postoperative outcomes of posterior lumbar interbody fusion (PLIF) and repeat discectomy for same-level recurrent disc herniation.

Methods

The patients included had previously undergone discectomy and presented with a same-level recurrent lumbar disc herniation. The patients were placed into two groups: 1) discectomy only, 2) PLIF based on the absence or presence of segmental instability. Preoperative and postoperative Oswestry disability index scores, duration of surgery, blood loss, duration of hospitalization, and complications were analyzed.

Results

The repeat discectomy and fusion groups had 40 and 34 patients, respectively. The patients were followed up for 2.68 (1-4) years. There was no difference in the duration of hospitalization (3.73 vs. 3.29 days P=0.581) and operative time (101.25 vs. 108.82 mins, P=0.48). Repeat discectomy had lower intraoperative blood loss, 88.75 ml (50-150) versus 111.47 ml (30-250) in PLIF (P=0.289). PLIF had better ODI pain score 4.21 (0-10) versus 9.27 (0-20) (P-value of 0.018). Recurrence was 22.5% in repeat discectomy versus 0 in PLIF.

Conclusion

PLIF and repeat discectomy for recurrent lumbar disc herniation have comparable intraoperative blood loss, duration of surgery, and hospital stay. PLIF is associated with lower durotomy rates and better long-term pain control than discectomy. This is due to recurrence and progression of degenerative process in discectomy patients, which are eliminated and slowed, respectively, by PLIF.

A rare case of rebleeding brainstem cavernoma in a 5-month-old-girl

Background

Brainstem cavernomas (BSCs) are relatively rare intracranial vascular lesions that, if left untreated, can be devastating to the patient. The lesions are associated with a myriad of symptoms, depending on their size and location. However, medullary lesions present acutely with cardiorespiratory dysfunction. We present the case of a 5-month-old child with a BSC.

Case Description

A 5-month-old child presented for the 2^nd time with sudden respiratory distress and excessive salivation. On the first presentation, brain magnetic resonance imaging (MRI) showed a 13 × 12 × 14 mm cavernoma at the pontomedullary junction. She was managed conservatively but presented 3 months later with tetraparesis, bulbar palsy, and severe respiratory distress. A repeat MRI showed enlargement of the cavernoma to 27 × 28 × 26 mm with hemorrhage in different stages. After hemodynamic stabilization, complete cavernoma resection was performed through the telovelar approach with neuromonitoring. Postoperatively, the child recovered motor function, but the bulbar syndrome persisted with hypersalivation. She was discharged on day 55 with a tracheostomy.

Conclusion

BSCs are rare lesions that are associated with severe neurological deficits due to the compactness of important cranial nerve nuclei and other tracts in the brainstem. Early surgical excision and hematoma evacuation for superficially presenting lesions can be lifesaving. However, the risk of postoperative neurological deficits is still a major concern in these patients.

Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas

In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.

Long-term outcomes after surgery for brainstem cavernous malformations: analysis of 46 consecutive cases

OBJECTIVE

The objective of this study was to evaluate the long-term outcomes after resection of brainstem cavernous malformations (BSCMs) and to assess the usefulness of the Lawton grading system in these cases.

METHODS

This retrospective study analyzed 46 consecutive patients with BSCMs operated on between July 1990 and December 2020. Outcomes at the last follow-up were defined as favorable (modified Rankin Scale [mRS] score 0-2) or unfavorable (mRS score > 2).

RESULTS

The study cohort comprised 24 men (52%) and 22 women (48%), ranging in age from 8 to 78 years old (median 37 years). In 19 patients (41%), the preoperative mRS score was > 2. All patients had hemorrhagic BSCM. There were 12 (26%) mesencephalic, 19 (41%) pontine, 7 (15%) medullary, and 8 (17%) cerebellar peduncle lesions, with a maximal diameter ranging from 5 to 40 mm (median 15 mm). In total, 24 BSCMs (52%) had bilateral extension crossing the brainstem midline. Lawton grades of 0, I, II, III, IV, V, and VI were defined in 3 (7%), 2 (4%), 10 (22%), 11 (24%), 8 (17%), 7 (15%), and 5 (11%) cases, respectively. Total resection of BSCMs was attained in 43 patients (93%). There were no perioperative deaths. Excluding the 3 most recent cases, the length of follow-up ranged from 56 to 365 months. The majority of patients demonstrated good functional recovery, but regress of the preexisting oculomotor nerve deficit was usually incomplete. No new hemorrhagic events were noted after total resection of BSCMs. In 42 patients (91%), the mRS score at the time of last follow-up was ≤ 2 (favorable outcome), and in 18 (39%), it was 0 (absence of neurological symptoms). Forty-four patients (96%) demonstrated clinical improvement and 2 (4%) had no changes compared with the preoperative period. Multivariate analysis revealed that only lower Lawton grade had a statistically significant independent association (p = 0.0280) with favorable long-term outcome. The area under the receiver operating characteristic curve for prediction of favorable outcome with 7 available Lawton grades of BSCM was 0.93.

CONCLUSIONS

Resection of hemorrhagic BSCMs by an experienced neurosurgeon may be performed safely and effectively, even in severely disabled patients. In the authors' experience, preexisting oculomotor nerve palsy represents the main cause of permanent postoperative neurological morbidity. The Lawton grading system effectively predicts long-term outcome after surgery.

Isolated tectal cavernomas: A comprehensive literature review with a case presentation

Intracranial cavernous angiomas or cavernomas (ICCs) are abnormal blood-filled vasculatures made of mono-endothelial layer and characterized by their bubble-like caverns. Brainstem cavernomas (BSCs) is a critical form of ICCs since slight changes in the lesion can result in devastating or life-threatening outcomes. We hereby present a rare case of BSC developed in the mesencephalic tectum with intraventricular bleeding and Parinaud’s Syndrome. Our patient was managed by complete surgical resection of the lesion through an infra-tentorial supracerebellar approach. Additionally, we reviewed and analyzed the hitherto reported cases of isolated tectal cavernomas (TCs) in the literature, including our case, to elucidate the main factors associated with the management outcomes of TCs. There have been 25 cases of isolated TC reported until now. Most of the patients were adults between 18–77 y of age, except for two children (7 and 13 y). There was no sex predominance. Symptomatic patients presented with headache 56%, altered level of consciousness 24%, and/or double vision 20%. Most cases (64%) had hemorrhagic lesions at presentation, and 60% of all cases experienced recurrent hemorrhages. Parinaud’s Syndrome was recorded in five cases, including the current one. All cases affected with Parinaud’s were males. Lesion size was a determinant of the outcome as larger lesions were more likely to result in persistent deficits. Surgical resection of the lesion was an effective management modality with ∼79% (15/19) of patients who underwent surgery ended up with complete recovery.

•

We reviewed and statistically analyzed all reported cases of isolated tectal cavernoma in PubMed literature.

•

Isolated tectal cavernoma is not associated with specific sex or a certain age.

•

The most common complication associated with this condition is hemorrhage (64%).

•

Parinaud’s Syndrome has been associated with some cases, with its presence being male predominant.

•

Lesion size is significantly associated with outcome as larger lesions (>11 mm) are more likely to induce persistent deficit.

•

Surgical resection is the ultimate management modality as most surgically treated cases ended with complete recovery (79%).

Resection of Brainstem Cavernous Malformations: Pearls and Pitfalls for Minimizing Complications

BACKGROUND

Surgical management of brainstem cavernous malformations (CMs) is a controversial topic in the field of neurosurgery. These lesions have a propensity to hemorrhage, thereby disrupting surrounding brainstem eloquence.

METHODS

This article provides the personal reflections of the senior author and a narrative literature review on resection of brainstem CMs.

RESULTS

Here we discuss the indications for microsurgery, microsurgical techniques and nuances, and perioperative management considerations necessary to minimize complications during resection of brainstem CMs, which are lesions of venous origin.

CONCLUSIONS

The natural history of the lesion, risk of future hemorrhage, and potential for symptom resolution should be carefully considered when planning to resect brainstem CMs. Nuanced microsurgical techniques with minimal disruption of normal tissues provide the best chance of satisfactory outcomes.