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El-Ghandour NMF. Commentary: Microsurgical Resection of a Medulla Oblongata Cavernoma: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01101. [PMID: 38531086 DOI: 10.1227/ons.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/28/2024] Open
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El-Ghandour NMF. Commentary: Lateral Supracerebellar, Infratentorial Approach for a Large Midbrain Cavernous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e232-e233. [PMID: 37427944 DOI: 10.1227/ons.0000000000000826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 07/11/2023] Open
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KUWANO A, YAMAGUCHI K, FUNATSU T, MOTEKI Y, EGUCHI S, MIURA I, UCHIDA M, ITO K, ISHIKAWA T, KAWAMATA T. A Case of Cavernous Malformation of the Midbrain Removed via an Interhemispheric Transcallosal Subchoroidal Approach. NMC Case Rep J 2022; 9:337-342. [PMID: 36381135 PMCID: PMC9633092 DOI: 10.2176/jns-nmc.2022-0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/11/2022] [Indexed: 11/05/2022] Open
Abstract
Cavernous malformations of the midbrain have a higher rate of hemorrhage and a poorer prognosis than vascular malformations of other brain areas. Surgical resection of these lesions is often necessary to avoid neurological deficits in affected patients. Herein, the literature surrounding cavernous malformations was examined, and the case of a 48-year-old man with left hemiparesis and diplopia caused by incomplete right oculomotor nerve palsy, who was diagnosed with a hemorrhage from a midbrain cavernous malformation, was discussed. The lesion expanded gradually on magnetic resonance imaging and was symptomatic; radical removal of the lesion before the onset of irreversible symptoms due to recurring bleeding was therefore considered to be beneficial for the patient. Surgical removal of the entire cavernous malformations of the midbrain was performed using an interhemispheric transcallosal subchoroidal approach, with excellent postoperative results and complete recovery from the oculomotor nerve palsy and left hemiparesis. This case shows that this approach is the most appropriate for surgical resections of lesions in the upper midbrain.
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Affiliation(s)
- Atsushi KUWANO
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Koji YAMAGUCHI
- Department of Neurosurgery, Tokyo Women's Medical University
| | | | - Yosuke MOTEKI
- Department of Neurosurgery, Tokyo Women's Medical University
| | | | - Isamu MIURA
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Momo UCHIDA
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Kaname ITO
- Department of Neurosurgery, Tokyo Women's Medical University
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Dammann P, Santos AN, Wan XY, Zhu Y, Sure U. Cavernous Malformations. Neurosurg Clin N Am 2022; 33:449-460. [DOI: 10.1016/j.nec.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Alexander AY, Leonel LCPC, Agosti E, Celda MP, Lanzino G. The precuneal interhemispheric, trans-tentorial corridor to the pineal region and brainstem, surgical anatomy, and case illustration. Acta Neurochir (Wien) 2022; 164:1095-1103. [PMID: 35266050 DOI: 10.1007/s00701-022-05167-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pineal region and dorsal midbrain are among the most challenging surgical targets. To approach lesions in this region that harbor a superior to inferior long axis, we describe the basic steps of the precuneal, interhemispheric, trans-tentorial approach and illustrate anatomical landmarks of this established, but not so popular, surgical trajectory. METHOD To study the anatomical landmarks and safety of this approach, the neurovascular anatomy was studied on 22 sides of 11 formalin-fixed latex-injected anatomical specimens. A step-by-step dissection of the precuneal interhemispheric trans-tentorial approach and study of the key anatomical landmarks was performed. An illustrative clinical case of a pontomesencephalic cavernous malformation (CM) resected through this approach is also detailed. RESULTS The mean distance from the transverse sinus to the most posterior cortical vein draining into the superior sagittal sinus was 6.4 cm. The mean distance from the calcarine sulcus to the most posterior cortical vein was 5.3 cm. Key steps of the dissection are as follows: craniotomy exposing the posterior aspect of the superior sagittal sinus (SSS), durotomy and gentle retraction of the SSS edge, dissection of the interhemispheric fissure, linear incision of the tentorium that extends anteriorly to the incisura and lateral reflection of the tentorium, and arachnoidal dissection and exposure of the cerebellomesencephalic fissure. CONCLUSION The precuneal, interhemispheric, trans-tentorial approach affords excellent access to the falcotentorial junction, splenium, pineal region, quadrigeminal cistern, and dorsal pons once the cerebellomesencephalic fissure has been dissected.
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Affiliation(s)
- A Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Maria Peris Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Giuseppe Lanzino
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA.
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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Kikuta KI, Isozaki M, Higashino Y, Kodera T, Arishima H, Matsuda K, Yamauchi T, Yamada S, Akazawa A, Kidoguchi M, Umeda H, Tsukinowa Y, Hagiwara R. Functional Outcomes of Microsurgical Resection for Cavernous Malformations of the Brainstem. Adv Tech Stand Neurosurg 2022; 44:121-132. [PMID: 35107676 DOI: 10.1007/978-3-030-87649-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Long-term functional outcomes of microsurgical resection for cavernous malformations of the brainstem (CMB) have been largely unknown. Favorable outcomes after CMB surgery might be related to the achievement of complete resection and mRS at 1 month after the surgery. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms tended to improve after surgery.We evaluated 25 consecutive patients with CMB surgically treated at our center between 2006 and 2021. The subjects included 11 men and 14 women, with ages ranging from 13 to 61 years (mean ± SD = 37 ± 12 years). Modified Rankin Scale (mRS) scores and neurological symptoms of the patients were evaluated before surgery, 1 month after surgery, and at the final follow-up at the outpatient clinic. The mean number of previous hemorrhages was 7 ± 1.0 and the mean lesion size was 21 ± 8 mm. The mRS scores on admission and at the final follow-up were 2.9 points and 1.7 points, respectively. The mRS scores at the final follow-up were significantly improved compared to those on admission. There was no statistical difference between the preoperative mRS and mRS at 1 month after the operation. Multivariable analysis indicated that mRS scores at 1 month after surgery were the most significant predictive factors for favorable outcomes. Complete resection was achieved in 24 of 33 operations. Incomplete resection was significantly related to the frequency of subsequent recurrent hemorrhage and high mRS scores at the final follow-up. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms improved significantly after surgery.
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Affiliation(s)
- Ken-Ichiro Kikuta
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.
| | - Makoto Isozaki
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshifumi Higashino
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Toshiaki Kodera
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hidetaka Arishima
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ken Matsuda
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Takahiro Yamauchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Shinsuke Yamada
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ayumi Akazawa
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masamune Kidoguchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hideto Umeda
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yu Tsukinowa
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ryota Hagiwara
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Yang Y, Velz J, Neidert MC, Lang W, Regli L, Bozinov O. The BSCM score: a guideline for surgical decision-making for brainstem cavernous malformations. Neurosurg Rev 2021; 45:1579-1587. [PMID: 34713352 PMCID: PMC8976795 DOI: 10.1007/s10143-021-01679-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
Microsurgical resection of brainstem cavernous malformations (BSCMs) can be performed today with acceptable morbidity and mortality. However, in this highly eloquent location, the indication for surgery remains challenging. We aimed to elaborate a score system that may help clinicians with their choice of treatment in patients with BSCMs in this study. A single-center series of 88 consecutive BSCMs patients with 272 follow-up visits were included in this study. Univariable and multivariable generalized estimating equations (GEE) were constructed to identify the association of variables with treatment decisions. A score scale assigned points for variables that significantly contributed to surgical decision-making. Surgical treatment was recommended in 37 instances, while conservative treatment was proposed in 235 instances. The mean follow-up duration was 50.4 months, and the mean age at decision-making was 45.9 years. The mean BSCMs size was 14.3 ml. In the multivariable GEE model, patient age, lesion size, hemorrhagic event(s), mRS, and axial location were identified as significant factors for determining treatment options. With this proposed score scale (grades 0–XII), non-surgery was the first option at grades 0–III. The crossover point between surgery and non-surgery recommendations lay between grades V and VI while surgical treatment was found in favor at grades VII–X. In conclusion, the proposed BSCM operating score is a clinician-friendly tool, which may help neurosurgeons decide on the treatment for patients with BSCMs.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland. .,Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
| | - Wei Lang
- Department of Geriatric Medicine, University Hospital Zurich, City Hospital Waid Zurich, Tiechestrasse 99, CH-8037, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
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Huang C, Bertalanffy H, Kar S, Tsuji Y. Microsurgical management of midbrain cavernous malformations: does lesion depth influence the outcome? Acta Neurochir (Wien) 2021; 163:2739-2754. [PMID: 34415444 PMCID: PMC8437888 DOI: 10.1007/s00701-021-04915-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
Background The purpose of this study was to clarify whether the intrinsic depth of midbrain cavernous malformations (MCMs) influenced the surgical outcome. Methods The authors conducted a retrospective study of 76 consecutive patients who underwent microsurgical resection of a MCM. The vascular lesions were categorized into 4 distinct groups based on how these lesions had altered the brainstem surface. Additionally, it was verified whether the actual aspect of the brainstem surface could be predicted only by evaluating the pertinent preoperative MRI slices. Clinical outcome was assessed by determining the modified Rankin Scale Score (mRS) before and after surgery. Results Twenty-three MCMs (30.3%) were located deeply within the midbrain. The overlying midbrain surface appeared to be normal (group nl). In 33 patients (43.4%), the midbrain surface showed only a yellowish discoloration (group yw). In another 14 individuals (18.4%), the midbrain surface was distorted by the underlying MCM and bulging out while the vascular lesion still remained covered by a thin parenchymal layer (group bg). In the smallest group comprising 6 patients (7.9%), the exophytic MCM had disrupted the midbrain surface and was clearly visible at microsurgical exposure (group ex). The mean mRS decreased in the group nl from 1.43 preoperatively to 0.61 at follow-up. Conclusion This study demonstrates in a large patient population that a deep intrinsic MCM location is not necessarily associated with an unfavorable clinical outcome after microsurgical lesionectomy. Predicting the aspect of the midbrain surface by evaluating preoperative MR images alone was not sufficiently reliable.
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Affiliation(s)
- Caiquan Huang
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Helmut Bertalanffy
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany.
| | - Souvik Kar
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
| | - Yoshihito Tsuji
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
- Department of Neurosurgery, Matsubara Tokushukai Hospital, Matsubara, Japan
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Bertalanffy H, Ichimura S, Kar S, Tsuji Y, Huang C. Optimal access route for pontine cavernous malformation resection with preservation of abducens and facial nerve function. J Neurosurg 2020; 135:683-692. [PMID: 33307526 DOI: 10.3171/2020.7.jns201023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the differences between posterolateral and posteromedial approaches to pontine cavernous malformations (PCMs) in order to verify the hypothesis that a posterolateral approach is more favorable with regard to preservation of abducens and facial nerve function. METHODS The authors conducted a retrospective analysis of 135 consecutive patients who underwent microsurgical resection of a PCM. The vascular lesions were first classified in a blinded fashion into 4 categories according to the possible or only reasonable surgical access route. In a second step, the lesions were assessed according to which approach was performed and different patient groups and subgroups were determined. In a third step, the modified Rankin Scale score and the rates of permanent postoperative abducens and facial nerve palsies were assessed. RESULTS The largest group in this series comprised 77 patients. Their pontine lesion was eligible for resection from either a posterolateral or posteromedial approach, in contrast to the remaining 3 patient groups in which the lesion location already had dictated a specific surgical approach. Fifty-four of these 77 individuals underwent surgery via a posterolateral approach and 23 via a posteromedial approach. When comparing these 2 patient subgroups, there was a statistically significant difference between postoperative rates of permanent abducens (3.7% vs 21.7%) and facial (1.9% vs 21.7%) nerve palsies. In the entire patient population, the abducens and facial nerve deficit rates were 5.9% and 5.2%, respectively, and the modified Rankin Scale score significantly decreased from 1.6 ± 1.1 preoperatively to 1.0 ± 1.1 at follow-up. CONCLUSIONS The authors' results suggest favoring a posterolateral over a posteromedial access route to PCMs in patients in whom a lesion is encountered that can be removed via either surgical approach. In the present series, the authors have found such a constellation in 57% of all patients. This retrospective analysis confirms their hypothesis in a large patient cohort. Additionally, the authors demonstrated that 4 types of PCMs can be distinguished by preoperatively evaluating whether only one reasonable or two alternative surgical approaches are available to access a specific lesion. The rates of postoperative sixth and seventh nerve palsies in this series are substantially lower than those in the majority of other published reports.
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Affiliation(s)
| | - Shinya Ichimura
- 1International Neuroscience Institute, Hannover, Germany
- 2Department of Neurosurgery, Kawasaki Chuo Clinic, Kawasaki; and
| | - Souvik Kar
- 1International Neuroscience Institute, Hannover, Germany
| | - Yoshihito Tsuji
- 1International Neuroscience Institute, Hannover, Germany
- 3Department of Neurosurgery, Matsubara Tokushukai Hospital, Matsubara, Japan
| | - Caiquan Huang
- 1International Neuroscience Institute, Hannover, Germany
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