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Gamma Knife® stereotactic radiosurgery for intracranial cavernous malformations. J Clin Neurosci 2022; 106:96-102. [DOI: 10.1016/j.jocn.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
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2
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Shim Y, Phi JH, Wang KC, Cho BK, Lee JY, Koh EJ, Kim KH, Lee EJ, Kim KJ, Kim SK. Clinical outcomes of pediatric cerebral cavernous malformation: an analysis of 124 consecutive cases. J Neurosurg Pediatr 2022; 30:474-483. [PMID: 36057124 DOI: 10.3171/2022.7.peds22299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE One-fourth of cerebral cavernous malformation (CCM) patients are children, but studies on these patients are scarce. This study aimed to identify the clinical presentation of pediatric CCM patients and to investigate clinical outcomes according to the treatment modalities applied on the basis of our institution's treatment strategy. METHODS The authors performed a retrospective analysis of 124 pediatric CCM patients with a follow-up of more than 1 year from 2000 to 2019. They performed resection (n = 62) on lesions causing intractable seizure, rebleeding, or mass effect and observed the clinical courses of patients with lesions in deep or eloquent areas without persistent symptoms (n = 52). Radiosurgery (n = 10) was performed when the patient refused resection or strongly desired radiosurgery. The authors investigated the clinical characteristics, performance status (modified Rankin Scale [mRS] score), and rebleeding rate at the 1-year and last follow-up examinations and compared these among 3 groups classified on the basis of treatment applied. The authors evaluated seizure outcomes at the 1-year and last follow-up examinations for the surgery (n = 32) and observation (n = 17) groups. Finally, the authors drew cumulative incidence curves for the discontinuation of antiepileptic drugs (AEDs) for patients in the surgery (n = 30) and observation (n = 9) groups. RESULTS The 3 groups showed slight differences in initial symptoms, lesion locations, and rates of recent hemorrhage. The proportion of patients with improved mRS score at the 1-year follow-up was significantly greater in the surgery group than in the other groups (67% of the surgery group, 52% observation group, and 40% radiosurgery group; p = 0.078), as well as at the last follow-up (73% surgery group, 54% observation group, and 60% radiosurgery group; p = 0.097). The surgery group also had the lowest rebleeding rate during the follow-up period (2% surgery group, 11% observation group, and 20% radiosurgery group; p = 0.021). At the 1-year follow-up, the proportion of seizure-free patients without AEDs was significantly higher in the surgery group than the observation group (88% surgery group vs 53% observation group, p < 0.001), and similar results were obtained at the last follow-up (91% surgery group vs 56% observation group, p = 0.05). The 5-year AED-free rates for the surgery and observation groups were 94% and 50%, respectively, on the cumulative incidence curve (p = 0.049). CONCLUSIONS The clinical presentation of pediatric CCM patients was not significantly different from that of adult patients. Lesionectomy may be acceptable for pediatric CCM patients with indications of persistent seizures despite AED medications, rebleeding, and mass effects.
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Affiliation(s)
- Youngbo Shim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Phi
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Chang Wang
- 2Neuro-oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Republic of Korea
| | - Byung-Kyu Cho
- 3Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Ji Yeoun Lee
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- 4Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Koh
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hyun Kim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Lee
- 5Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Joong Kim
- 6Division of Pediatric Neurology, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; and
| | - Seung-Ki Kim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- 7Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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3
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Bubenikova A, Skalicky P, Benes V, Benes V, Bradac O. Overview of cerebral cavernous malformations: comparison of treatment approaches. J Neurol Neurosurg Psychiatry 2022; 93:475-480. [PMID: 35273070 DOI: 10.1136/jnnp-2021-328658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/31/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The comparison of treatment efficacy for cerebral cavernous malformations (CCMs) has not yet been well researched. DESIGN PubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase and additional sources were searched to identify cohort studies about the treatment of CCMs published between 1990 and 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed; the Newcastle-Ottawa Scale was used to assess the risk of bias and to evaluate limitations based on selection/outcome biases. The cumulative incidences with 95% CIs were calculated using the random effects model. The models of Poisson distribution were applied to evaluate risk factors of poorer treatment outcome by calculating rate ratios within 100 person-years with 95% CIs. RESULTS A total of 100 cohorts yielding 8994 patients treated for CCMs within 41 098 person-years of follow-up were analysed. The efficacy of ensuring the prevention of haemorrhage was 97% in surgical, 86% in radiosurgical and 77% in the conservative treatment. The lowest mortality (1%) was after radiosurgery, and the highest persistent morbidity (22%) was in natural history series. Deep-seated and brainstem CCMs were associated with higher bleeding rates. Lobar localisation was a protective factor in all analyses. Patients with history of previous haemorrhage were exposed to higher risk of rebleeding. Male gender was a protective factor associated with lower risk of post-treatment haemorrhage. CONCLUSIONS Surgical resection of CCM is effective in ensuring the prevention of haemorrhage with acceptable morbidity and mortality, but conservative and radiosurgical management is a justified treatment alternative. Brainstem and deep-seated CCMs are predominantly associated with higher haemorrhage rates.
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Affiliation(s)
- Adela Bubenikova
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Skalicky
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Bradac
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic .,Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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Magnetic Resonance Imaging of Multiple Cerebral and Spinal Cavernous Malformations of a Patient with Dementia and Tetraparesis. Diagnostics (Basel) 2022; 12:diagnostics12030677. [PMID: 35328230 PMCID: PMC8946930 DOI: 10.3390/diagnostics12030677] [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: 01/24/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022] Open
Abstract
Cavernomas are rare cerebrovascular malformations that usually occur in sporadic forms with solitary lesions located most often in the hemispheric white matter, but also in the infratentorial or spinal region. Multiple lesions at different CNS levels are considered a hallmark for the familial form of the disease. The diagnostic modality of choice for cerebral cavernous malformations (CCMs) is magnetic resonance imaging (MRI). We present an intriguing case of a 65-year-old male admitted to our hospital with tetraparesis and cognitive impairment where highly sensitive MRI sequences identified many cerebral cavernous lesions at the supra-, infratentorial and cervical–thoracic spine levels, some of them with recent signs of bleeding in a patient with oral anticoagulant therapy due to atrial fibrillation. The mechanism of cognitive impairment in this patient is most probably the interruption of strategic white matter tracts, as it is known to happen in other subcortical vascular pathologies. MRI can be helpful not only in mapping the anatomical distribution of lesions, but also in weighing the risks and making decisions regarding whether or not to continue oral anticoagulant therapy.
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Fotakopoulos G, Andrade-Barazarte H, Kivelev J, Tjahjadi M, Goehre F, Hernesniemi J. Brainstem Cavernous Malformations Management: Microsurgery vs. Radiosurgery, a Meta-Analysis. Front Surg 2022; 8:630134. [PMID: 35083267 PMCID: PMC8784390 DOI: 10.3389/fsurg.2021.630134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece
- *Correspondence: George Fotakopoulos
| | | | - Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mardjono Tjahjadi
- Department of Surgery, Atmajaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Felix Goehre
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
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Shen CC, Sun MH, Yang MY, You WC, Sheu ML, Chen YJ, Chen YJ, Sheehan J, Pan HC. Outcome of intracerebral cavernoma treated by Gamma Knife radiosurgery based on a double-blind assessment of treatment indication. Radiat Oncol 2021; 16:164. [PMID: 34454542 PMCID: PMC8401103 DOI: 10.1186/s13014-021-01885-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefit and the risk profile of Gamma Knife radiosurgery (GKRS) for intracerebral cavernoma remains incompletely defined in part due to the natural history of low incidence of bleeding and spontaneous regression of this vascular malformation. In this study, we retrieved cases from a prospectively collected database to assess the outcome of intracerebral cavernoma treated with GKRS using a double blinded review process for treatment. METHODS From 2003 to 2018, there were 94 cases of cavernoma treated by GKRS in the doubly blinded assessments by two experienced neurological and approved for GKRS treatment. All the patients received GKRS with margin dose of 11-12 (Gray) Gy and afterwards were assessed for neurological outcome, radiologic response, and quality of life. RESULTS The median age of the patients was 48 (15-85) years with median follow up of 77 (26-180) months post SRS. The mean target volume was 1.93 ± 3.45 cc. In those who has pre-SRS epilepsy, 7 of 16 (43.7%) achieved seizure freedom (Engel I/II) and 9 of 16 (56.3%) achieved decreased seizures (Engel III) after SRS. Rebleeding occurred in 2 cases (2.1%) at 13 and 52 months post SRS. The radiologic assessment demonstrated 20 (21.3%) cases of decreased cavernoma volume, 69 (73.4%) were stable, and 5 (7.3%) increased size. Eighty-seven of 94 (92.5%) cases at the last follow up achieve improvement in their quality of life, but 7 cases (7.4%) showed a deterioration. In statistical analysis, the effective seizure control class (Engel I/II) was highly correlated with patient harboring a single lesion (p < 0.05) and deep seated location of the cavernoma (p < 0.01). New neurological deficits were highly correlated with decreased mental (p < 0.001) and physical (p < 0.05) components of quality of life testing, KPS (p < 0.001), deep seated location (p < 0.01), and increased nidus volume (p < 0.05). Quality of life deterioration either in physical component (p < 0.01), mental component (p < 0.01), and KPS (p < 0.05) was highly correlated with increased cavernoma volume. CONCLUSION Low margin dose GKRS for intracerebral cavernoma offers reasonable seizure control and improved quality of life while conferring a low risk of treatment complications including adverse radiation effect.
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Affiliation(s)
- Chiung-Chyi Shen
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan.,Basic Medical Education Center, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Ming Hsi Sun
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meng-Yin Yang
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meei-Ling Sheu
- Institute of Biomedical Science, National Chung-Hsin University, Taichung, Taiwan
| | - Yen-Ju Chen
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying Ju Chen
- College of Humanities and Social Sciences, Providence University, Taichung, Taiwan
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Hung-Chuan Pan
- Department of Medical Research and Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, Taichung, 40705, Taiwan. .,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.
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7
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Abstract
Cerebral cavernous malformations (CCMs) are neurovascular abnormalities characterized by thin, leaky blood vessels resulting in lesions that predispose to haemorrhages, stroke, epilepsy and focal neurological deficits. CCMs arise due to loss-of-function mutations in genes encoding one of three CCM complex proteins, KRIT1, CCM2 or CCM3. These widely expressed, multi-functional adaptor proteins can assemble into a CCM protein complex and (either alone or in complex) modulate signalling pathways that influence cell adhesion, cell contractility, cytoskeletal reorganization and gene expression. Recent advances, including analysis of the structures and interactions of CCM proteins, have allowed substantial progress towards understanding the molecular bases for CCM protein function and how their disruption leads to disease. Here, we review current knowledge of CCM protein signalling with a focus on three pathways which have generated the most interest—the RhoA–ROCK, MEKK3–MEK5–ERK5–KLF2/4 and cell junctional signalling pathways—but also consider ICAP1-β1 integrin and cdc42 signalling. We discuss emerging links between these pathways and the processes that drive disease pathology and highlight important open questions—key among them is the role of subcellular localization in the control of CCM protein activity.
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Affiliation(s)
- Valerie L Su
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
| | - David A Calderwood
- Department of Pharmacology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA.,Department of Cell Biology, Yale University School of Medicine, PO Box 208066, 333 Cedar Street, New Haven, CT 06520, USA
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8
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Cavalcanti DD, Figueiredo EG, Preul MC, Spetzler RF. Anatomical and Objective Evaluation of the Main Surgical Approaches to Pontine Intra-Axial Lesions. World Neurosurg 2019; 121:e207-e214. [DOI: 10.1016/j.wneu.2018.09.077] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/26/2022]
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9
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Wen R, Shi Y, Gao Y, Xu Y, Xiong B, Li D, Gong F, Wang W. The Efficacy of Gamma Knife Radiosurgery for Cavernous Malformations: A Meta-Analysis and Review. World Neurosurg 2018; 123:371-377. [PMID: 30583131 DOI: 10.1016/j.wneu.2018.12.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This meta-analysis is to evaluate the clinical efficacy of gamma knife radiosurgery (GKRS) for treating cavernous malformations. METHODS PubMed, Ovid Embase, and Ovid Medline electronic databases were searched. The primary outcome is hemorrhage rate and this meta-analysis is performed. RESULTS Nine studies are included in this meta-analysis. The overall risk ratio (RR) of hemorrhage rate of pre-GKRS and post-GKRS is 6.08 (95% confidence interval [CI], 5.04-7.35). The overall RR is 3.03 (95% CI, 2.65-4.11) between the hemorrhage rate of pre-GKRS and the first 2 years postradiosurgery, and the overall RR is 12.13 (95% CI, 1.73-85.07) comparing pre-GKRS with 2 years after GKRS. There is no significant difference of the hemorrhage rate between the first 2 years postradiosurgery and 2 years after GKRS (RR = 2.81; 95% CI, 0.20-13.42). The neurologic deficiency is the most common radiosurgery-related complication. CONCLUSIONS Patients with cerebral cavernous malformations, especially ones that were deep seated and surgically inaccessible, seem to benefit from GKRS owing to a reduction of annual hemorrhage rate in the first 2 years and 2 years after, despite several cases that suffer from negative side effects of radiation.
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Affiliation(s)
- Rong Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yifeng Shi
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Botao Xiong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Denghui Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Feilong Gong
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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10
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Singh H, Elarjani T, da Silva HB, Shetty R, Kim L, Sekhar LN. Brain Stem Cavernous Malformations: Operative Nuances of a Less-Invasive Resection Technique. Oper Neurosurg (Hagerstown) 2018; 15:153-173. [PMID: 29228395 DOI: 10.1093/ons/opx231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/27/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Different operative techniques are reported for the resection of brainstem cavernous malformations (BSCMs). The senior author has previously reported on a less-invasive technique of entering the brain stem with piecemeal removal of BSCMs, especially the deep-seated ones. OBJECTIVE To present a larger series of these lesions, emphasizing the approach to the brain stem via case selection. We discuss the nuances of the less-invasive operative technique through case illustrations and intraoperative videos. METHODS A retrospective review of 46 consecutive cases of BSCMs, with their clinical and radiographic data, was performed. Nine cases were selected to illustrate 7 different operative approaches, and discuss surgical nuances of the less-invasive technique unique to each. RESULTS Postoperative morbidity, defined as an increase in modified Rankin Scale, was observed in 5 patients (10.9%). A residual BSCM was present in 2 patients (4.3%); both underwent reoperation to remove the remainder. At follow-up of 31.1 ± 27.8 mo, 3 patients experienced recurrence (6.5%). Overall, 65% of our patients improved, 20% stayed the same, and 11% worsened postsurgery. Two patients died, yielding a mortality of 4.3%. CONCLUSION Using the less-invasive resection technique for piecemeal BSCM removal, in appropriately selected patients, has yielded comparable to improved patient outcomes over existing large series. In our experience, lateral, anterolateral, and posterolateral approaches are favorable over direct midline (dorsal or ventral) approaches. A thorough understanding of brain-stem safe-entry zones, in conjunction with appropriate approach selection, is key to a good outcome in challenging cases.
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Affiliation(s)
- Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Turki Elarjani
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Harley Brito da Silva
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Rakshith Shetty
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Louis Kim
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
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11
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Affiliation(s)
- Christopher J Stapleton
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Fred G Barker
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston.
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12
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López-Serrano R, Martínez NE, Kusak ME, Quirós A, Martínez R. Significant Hemorrhage Rate Reduction after Gamma Knife Radiosurgery in Symptomatic Cavernous Malformations: Long-Term Outcome in 95 Case Series and Literature Review. Stereotact Funct Neurosurg 2017; 95:369-378. [DOI: 10.1159/000480664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/23/2017] [Indexed: 11/19/2022]
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13
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Abstract
Cavernous malformations of the thalamus represent a particularly complex subset of cavernous malformations because of the highly eloquent nature of the involved tissue and their deep location. The decision about whether to operate on any individual lesion depends on the specific location of the lesion within the thalamus, the nature of the patient's symptoms, and the patient's history. When surgery is recommended, the approach must be chosen carefully. Each part of the thalamus is reached by a different surgical approach. These approaches include the orbitozygomatic approach to the anteroinferior thalamus, the anterior interhemispheric transcallosal approach to the medial thalamus, the anterior contralateral interhemispheric transcallosal approach to the lateral thalamus, the posterior interhemispheric transcallosal approach to the posterosuperior thalamus, the parieto-occipital transventricular approach to the lateral posteroinferior thalamus, and the suboccipital supracerebellar infratentorial/transtentorial approach to the medial posteroinferior thalamus. Careful attention to safe entry zones and image guidance can allow safe removal of these lesions when necessary.
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Affiliation(s)
- Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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14
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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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15
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Taslimi S, Modabbernia A, Amin-Hanjani S, Barker FG, Macdonald RL. Natural history of cavernous malformation: Systematic review and meta-analysis of 25 studies. Neurology 2016; 86:1984-91. [PMID: 27164680 DOI: 10.1212/wnl.0000000000002701] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/21/2016] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE We pooled the results of studies on natural history of cavernous malformations (CM) to calculate point estimates and investigate main sources of heterogeneity. METHODS We searched MEDLINE, EMBASE, and ISI Web of Science for relevant studies published before May 2015. We used fixed or random effects models and meta-regression to pool the data. RESULTS Twenty-five studies were entered into the meta-analysis (90-1,295 patients depending on the analysis). Bleeding was defined as symptomatic hemorrhage plus radiologic evidence of hemorrhage. Sources of heterogeneity were identified as mixture of hemorrhage and rehemorrhage, mixture of rehemorrhage before and after 2 years of first bleeding, brainstem vs other locations, and calculation method. The rehemorrhage rate was higher than the hemorrhage rate (incidence rate ratio 16.5, p < 0.001, 95% confidence interval [CI] 9.7-28.0). Rehemorrhage within 2 years of the first hemorrhage was higher than after that (incidence rate ratio 1.8, p = 0.042, 95% CI 1.5-2.0). In two metaregression models, rough estimate of the annual incidence rate of hemorrhage was 0.3% (95% CI 0.1%-0.5%) and 2.8% (2.5%-3.3%) per person year in nonbrainstem and brainstem lesions and rough estimate of annual rehemorrhage rate per person year was 6.3% (3%-13.2%) and 32.3% (19.8%-52.7%) in nonbrainstem and brainstem lesions. Median time to rehemorrhage was 10.5 months. Posthemorrhage full recovery was 38.8%/person-year (28.7%-48.8%). Posthemorrhage full recovery or minimal disability was 79.5%/person-year (74.3%-84.8%). Mortality after bleeding was 2.2%. CONCLUSIONS The incidence of symptomatic hemorrhage or rehemorrhage is higher in brainstem lesions. First symptomatic hemorrhage increases the chance of symptomatic rehemorrhage, which decreases after 2 years.
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Affiliation(s)
- Shervin Taslimi
- From the Division of Neurosurgery (S.T.), University of Toronto, Canada; Department of Psychiatry (A.M.), Icahn School of Medicine, Mount Sinai Hospital, New York, NY; Department of Neurosurgery (S.A.-H.), University of Illinois at Chicago; Neurosurgical Service (F.G.B.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurosurgery (R.L.M.), St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science; and the Department of Surgery (R.L.M.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Canada
| | - Amirhossein Modabbernia
- From the Division of Neurosurgery (S.T.), University of Toronto, Canada; Department of Psychiatry (A.M.), Icahn School of Medicine, Mount Sinai Hospital, New York, NY; Department of Neurosurgery (S.A.-H.), University of Illinois at Chicago; Neurosurgical Service (F.G.B.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurosurgery (R.L.M.), St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science; and the Department of Surgery (R.L.M.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Canada
| | - Sepideh Amin-Hanjani
- From the Division of Neurosurgery (S.T.), University of Toronto, Canada; Department of Psychiatry (A.M.), Icahn School of Medicine, Mount Sinai Hospital, New York, NY; Department of Neurosurgery (S.A.-H.), University of Illinois at Chicago; Neurosurgical Service (F.G.B.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurosurgery (R.L.M.), St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science; and the Department of Surgery (R.L.M.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Canada
| | - Fred G Barker
- From the Division of Neurosurgery (S.T.), University of Toronto, Canada; Department of Psychiatry (A.M.), Icahn School of Medicine, Mount Sinai Hospital, New York, NY; Department of Neurosurgery (S.A.-H.), University of Illinois at Chicago; Neurosurgical Service (F.G.B.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurosurgery (R.L.M.), St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science; and the Department of Surgery (R.L.M.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Canada
| | - R Loch Macdonald
- From the Division of Neurosurgery (S.T.), University of Toronto, Canada; Department of Psychiatry (A.M.), Icahn School of Medicine, Mount Sinai Hospital, New York, NY; Department of Neurosurgery (S.A.-H.), University of Illinois at Chicago; Neurosurgical Service (F.G.B.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Neurosurgery (R.L.M.), St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science; and the Department of Surgery (R.L.M.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Canada.
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Zabramski JM, Kalani MYS, Filippidis AS, Spetzler RF. Propranolol Treatment of Cavernous Malformations with Symptomatic Hemorrhage. World Neurosurg 2016; 88:631-639. [DOI: 10.1016/j.wneu.2015.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 10/22/2022]
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Gross BA, Du R, Orbach DB, Scott RM, Smith ER. The natural history of cerebral cavernous malformations in children. J Neurosurg Pediatr 2016; 17:123-128. [PMID: 26474098 DOI: 10.3171/2015.2.peds14541] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECT Cerebral cavernous malformations (CMs) are a source of neurological morbidity from seizures and focal neurological deficits due to mass effect and hemorrhage. Although several natural history reports exist for adults with CMs, similar data for pediatric patients are limited. METHODS The authors reviewed hospital databases to identify children with CMs who had not been treated surgically and who had clinical and radiological follow-up. Annual hemorrhage rates were calculated in lesion-years, and risk factors were assessed using the Cox proportional hazards model. RESULTS In a cohort of 167 patients with 222 CMs, the mean patient age at the time of diagnosis was 10.1 years old (SD 6.0). Ninety patients (54%) were male. One hundred four patients (62%) presented with hemorrhage from at least 1 CM, 58 (35%) with seizures with or without CM hemorrhage, and 43 (26%) with incidental lesions. Twenty-five patients (15%) had multiple CMs, 17 (10%) had a family history of CMs, and 33 (20%) had radiologically apparent developmental venous anomalies (DVAs). The overall annual hemorrhage rate was 3.3%. Permanent neurological morbidity was 29% per hemorrhage, increasing to 45% for brainstem, thalamic, or basal ganglia CM and decreasing to 15% for supratentorial lobar or cerebellar lesions. The annual hemorrhage rate for incidental CMs was 0.5%; for hemorrhagic CMs, it was 11.3%, increasing to 18.2% within the first 3 years. Hemorrhage clustering within 3 years was statistically significant (HR 6.1, 95% CI 1.72-21.7, p = 0.005). On multivariate analysis, hemorrhagic presentation (HR 4.63, 95% CI 1.53-14.1, p = 0.007), brainstem location (HR 4.42, 95% CI 1.57-12.4, p = 0.005), and an associated radiologically apparent DVA (HR 2.91, 95% CI 1.04-8.09, p = 0.04) emerged as significant risk factors for hemorrhage, whereas age, sex, CM multiplicity, and CM family history did not. CONCLUSIONS Prior hemorrhage, brainstem location, and associated DVAs are significant risk factors for symptomatic hemorrhage in children with CMs. Hemorrhage clustering within the first 3 years of a bleed can occur, a potentially important factor in patient management and counseling.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital.,Department of Neurological Surgery; and.,Division of Neurointerventional Radiology, Boston Children's Hospital.,Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Department of Neurological Surgery, Brigham and Women's Hospital.,Harvard Medical School, Boston, Massachusetts
| | - Darren B Orbach
- Division of Neurointerventional Radiology, Boston Children's Hospital.,Harvard Medical School, Boston, Massachusetts
| | - R Michael Scott
- Department of Neurological Surgery; and.,Harvard Medical School, Boston, Massachusetts
| | - Edward R Smith
- Department of Neurological Surgery; and.,Harvard Medical School, Boston, Massachusetts
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18
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Kwon PM, Evans RW, Grosberg BM. Cerebral Vascular Malformations and Headache. Headache 2015; 55:1133-42. [DOI: 10.1111/head.12639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Patrick M. Kwon
- Department of Neurology; Icahn School of Medicine at Mount Sinai; New York NY USA
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19
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Gross BA, Du R. Cerebral cavernous malformations: natural history and clinical management. Expert Rev Neurother 2015; 15:771-7. [DOI: 10.1586/14737175.2015.1055323] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Shin SS, Murdoch G, Hamilton RL, Faraji AH, Kano H, Zwagerman NT, Gardner PA, Lunsford LD, Friedlander RM. Pathological response of cavernous malformations following radiosurgery. J Neurosurg 2015; 123:938-44. [PMID: 26090838 DOI: 10.3171/2014.10.jns14499] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) is a therapeutic option for repeatedly hemorrhagic cavernous malformations (CMs) located in areas deemed to be high risk for resection. During the latency period of 2 or more years after SRS, recurrent hemorrhage remains a persistent risk until the obliterative process has finished. The pathological response to SRS has been studied in relatively few patients. The authors of the present study aimed to gain insight into the effect of SRS on CM and to propose possible mechanisms leading to recurrent hemorrhages following SRS. METHODS During a 13-year interval between 2001 and 2013, bleeding recurred in 9 patients with CMs that had been treated using Gamma Knife surgery at the authors' institution. Microsurgical removal was subsequently performed in 5 of these patients, who had recurrent hemorrhages between 4 months and 7 years after SRS. Specimens from 4 patients were available for analysis and used for this report. RESULTS Histopathological analysis demonstrated that vascular sclerosis develops as early as 4 months after SRS. In the samples from 2 to 7 years after SRS, sclerotic vessels were prominent, but there were also vessels with incomplete sclerosis as well as some foci of neovascularization. CONCLUSIONS Recurrent bleeding after SRS for CM could be related to incomplete sclerosis of the vessels, but neovascularization may also play a role.
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Affiliation(s)
| | - Geoffrey Murdoch
- Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronald L Hamilton
- Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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21
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Kida Y, Hasegawa T, Iwai Y, Shuto T, Satoh M, Kondoh T, Hayashi M. Radiosurgery for symptomatic cavernous malformations: A multi-institutional retrospective study in Japan. Surg Neurol Int 2015; 6:S249-57. [PMID: 26005588 PMCID: PMC4434491 DOI: 10.4103/2152-7806.157071] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/29/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND A group study for symptomatic cavernous malformation (CM) treated with gamma knife (GK) surgery was performed. METHODS A total of 298 cases collected from 23 GK centers across Japan were included. Hemorrhage was the most common manifestation, followed by seizures and neurological deficits. Most of the lesions were located in the brainstem and basal ganglia, followed by the cerebral or cerebellar hemispheres. The CMs, which had a mean diameter of 14.8 mm, were treated using GK surgery with a mean marginal dose of 14.6 Gy. RESULTS In terms of hemorrhage-free survival (HFS), a marked dissociation was confirmed between the hemorrhage and seizure groups, while no obvious difference was noted between sexes. Superficial CMs located in cerebellum or lobar regions responded to the treatment better than deeply located CMs in the basal ganglia or brainstem. No significant difference of dose-dependent response was seen for three different ranges of marginal dose: Less than 15 Gy, between 15 and 20 Gy, and more than 20 Gy. Complications were more frequent after a marginal dose of over 15 Gy and in patients with lesions more than 15 mm in diameter. The rates of annual hemorrhage were estimated to be 7.4% during the first 2 years after radiosurgery and 2.8% thereafter. The overall hemorrhage rate after radiosurgery was 4.4%/year/patient. CONCLUSION The risk of hemorrhage is considerably reduced after GK treatment. The HFS as well as annual hemorrhage rate after GK treatment was apparently superior to that after conservative treatment for symptomatic CMs. To optimize the success of GK treatment, it is important to reduce the incidence of complications.
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Affiliation(s)
- Yoshihisa Kida
- Department of Neurosurgery, General Kamiiida Daiichi Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Toshinori Hasegawa
- Department of Neurosurgery, Komaki City Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Yoshiyasu Iwai
- Department of Neurosurgery, Osaka General Medical Center, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Takashi Shuto
- Department of Neurosurgery, Yokohama Rosai Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Manabu Satoh
- Department of Neurosurgery, Rakusai Shimizu Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Scientific Committee of Japanese Gamma Knife Society, Japan
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Azimi P, Shahzadi S, Bitaraf MA, Azar M, Alikhani M, Zali A, Sadeghi S. Cavernomas: Outcomes after gamma-knife radiosurgery in Iran. Asian J Neurosurg 2015; 10:49. [PMID: 25767582 PMCID: PMC4352634 DOI: 10.4103/1793-5482.151515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients. Materials and Methods: A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records. Results: The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm3 (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. Conclusion: The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.
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Affiliation(s)
- Parisa Azimi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sohrab Shahzadi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Maziar Azar
- Department of Neurosurgery, Tehran University of Medical science, Tehran, Iran
| | - Mazdak Alikhani
- Department of Neurosurgery Iran Gamma-Knife Center, Tehran, Iran
| | - Alireza Zali
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sohrab Sadeghi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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23
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Almefty KK, Spetzler RF. Management of Brainstem Cavernous Malformations. World Neurosurg 2015; 83:317-9. [DOI: 10.1016/j.wneu.2014.03.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 03/07/2014] [Indexed: 11/25/2022]
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Kim BS, Yeon JY, Kim JS, Hong SC, Lee JI. Gamma knife radiosurgery of the symptomatic brain stem cavernous angioma with low marginal dose. Clin Neurol Neurosurg 2014; 126:110-4. [DOI: 10.1016/j.clineuro.2014.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/04/2014] [Accepted: 08/25/2014] [Indexed: 10/24/2022]
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25
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Adachi K, Hasegawa M, Hayashi T, Nagahisa S, Hirose Y. A review of cavernous malformations with trigeminal neuralgia. Clin Neurol Neurosurg 2014; 125:151-4. [PMID: 25129386 DOI: 10.1016/j.clineuro.2014.07.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/16/2014] [Accepted: 07/20/2014] [Indexed: 11/26/2022]
Abstract
Cavernous malformation with trigeminal neuralgia is relatively rare; only 10 cases have been reported. In deciding treatment strategies, it is helpful to classify cavernous malformation according to its origin, as follows: in the Gasserian ganglion (Type G); between the cisternal and intra-axial portions of the trigeminal nerve root (Type C); in the intra-axial trigeminal nerve root in the pons (Type P); or in the spinal tract of the trigeminal nerve root (Type S). A 62-year-old male presented with left trigeminal neuralgia (V2 area) and left facial hypoesthesia. Imaging studies revealed a cerebellopontine angle mass lesion with characteristics of a cavernous malformation and evidence of hemorrhage. The lesion was completely removed via a left anterior transpetrosal approach. The mass was attached to the trigeminal nerve root; it was located between the cisternal and intra-axial portions of the nerve root, and feeding off microvessels from the trigeminal nerve vascular plexus. Histological examination confirmed a cavernous malformation. In this case, the cavernous malformation was Type C. We review cases of cavernous malformation with trigeminal neuralgia and discuss therapeutic strategies according to the area of origin.
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Affiliation(s)
- Kazuhide Adachi
- Department of Neurosurgery, School of Medicine, Fujita Health University, 1-98, Kutsugake Dengakugakubo, Toyoake City, Aichi 470-1192, Japan.
| | - Mitsuhiro Hasegawa
- Department of Neurosurgery, School of Medicine, Fujita Health University, 1-98, Kutsugake Dengakugakubo, Toyoake City, Aichi 470-1192, Japan
| | - Takuro Hayashi
- Department of Neurosurgery, School of Medicine, Fujita Health University, 1-98, Kutsugake Dengakugakubo, Toyoake City, Aichi 470-1192, Japan
| | - Shinya Nagahisa
- Department of Neurosurgery, School of Medicine, Fujita Health University, 1-98, Kutsugake Dengakugakubo, Toyoake City, Aichi 470-1192, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, School of Medicine, Fujita Health University, 1-98, Kutsugake Dengakugakubo, Toyoake City, Aichi 470-1192, Japan
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Choudhri O, Feroze AH, Lad EM, Kim JW, Plowey ED, Karamchandani JR, Chang SD. Co-occurrence of a cerebral cavernous malformation and an orbital cavernous hemangioma in a patient with seizures and visual symptoms: Rare crossroads for vascular malformations. Surg Neurol Int 2014; 5:S148-54. [PMID: 25071938 PMCID: PMC4109172 DOI: 10.4103/2152-7806.134810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 05/01/2014] [Indexed: 01/17/2023] Open
Abstract
Background: Cerebral cavernous malformations (CCMs) are angiographically occult vascular malformations of the central nervous system. As a result of hemorrhage and mass effect, patients may present with focal neurologic deficits, seizures, and other symptoms necessitating treatment. Once symptomatic, most often from hemorrhage, CCMs are treated with microsurgical resection. Orbital cavernous hemangiomas (OCHs) are similar but distinct vascular malformations that present within the orbital cavity. Even though CCMs and OCHs are both marked by dilated endothelial-lined vascular channels, they are infrequently seen in the same patient. Case Description: We provide a brief overview of the two related pathologies in the context of a patient presenting to our care with concomitant lesions, which were both resected in full without complication. Conclusion: This is the first known report that describes a case of concomitant CCM and OCH and explores the origins of two pathologies that are rarely encountered together in neurosurgical practice. Recognition of disparate symptomatologies is important for properly managing these patients.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, Canada
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, Canada
| | - Eleonora M Lad
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, Canada
| | - Jonathan W Kim
- Department of Ophthalmology, University of Southern California Keck School of Medicine, Los Angeles, California, Canada
| | - Edward D Plowey
- Department of Pathology, Stanford University Medical Center, Stanford, California, Canada
| | - Jason R Karamchandani
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Steven D Chang
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, Canada
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27
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Walcott BP, Peterson RT. Zebrafish models of cerebrovascular disease. J Cereb Blood Flow Metab 2014; 34:571-7. [PMID: 24517974 PMCID: PMC3982096 DOI: 10.1038/jcbfm.2014.27] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/27/2013] [Accepted: 01/07/2014] [Indexed: 12/18/2022]
Abstract
Perturbations in cerebral blood flow and abnormalities in blood vessel structure are the hallmarks of cerebrovascular disease. While there are many genetic and environmental factors that affect these entities through a heterogeneous group of disease processes, the ultimate final pathologic insult in humans is defined as a stroke, or damage to brain parenchyma. In the case of ischemic stroke, blood fails to reach its target destination whereas in hemorrhagic stroke, extravasation of blood occurs outside of the blood vessel lumen, resulting in direct damage to brain parenchyma. As these acute events can be neurologically devastating, if not fatal, development of novel therapeutics are urgently needed. The zebrafish (Danio rerio) is an attractive model for the study of cerebrovascular disease because of its morphological and physiological similarity to human cerebral vasculature, its ability to be genetically manipulated, and its fecundity allowing for large-scale, phenotype-based screens.
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Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Randall T Peterson
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
- Broad Institute, Cambridge, Massachusetts, USA
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28
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Sager O, Beyzadeoglu M, Dincoglan F, Uysal B, Gamsiz H, Demiral S, Oysul K, Dirican B, Sirin S. Evaluation of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) for cerebral cavernous malformations: a 15-year single-center experience. Ann Saudi Med 2014; 34:54-8. [PMID: 24658554 PMCID: PMC6074929 DOI: 10.5144/0256-4947.2014.54] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Surgery is the principal treatment for safely accessible hemorrhagic and symptomatic cavernous malformations. Nevertheless, the role of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) in the management of high-risk, symptomatic cavernoma lesions warrants further refinement. In this study, we evaluate the use of LINAC-based SRS for cerebral cavernous malformations (CMs) and report our 15-year single-center experience. DESIGN AND SETTINGS A retrospective study from the Department of Radiation Oncology and the Department of Neurosurgery at Gulhane Military Medical Academy and Medical Faculty, Ankara from April 1998 to June 2013. PATIENTS AND METHODS Fifty-two patients (22 females and 30 males) with cerebral CM referred to our department underwent high-precision single-dose SRS using a LINAC with 6-MV photons. All patients had at least 1 bleeding episode prior to radiosurgery along with related symptoms. Median dose prescribed to the 85% to 95% isodose line encompassing the target volume was 15 Gy (range, 10-20). RESULTS Out of the total 52 patients, follow-up data were available for 47 patients (90.4%). Median age was 35 years (range, 19-63). Median follow-up time was 5.17 years (range, 0.08-9.5) after SRS. Three hemorrhages were identified in the post-SRS period. Statistically significant decrease was observed in the annual hemorrhage rate after radiosurgical treatment (pre-SRS 39% vs post-SRS 1.21, P < .0001). Overall, there were no radiosurgery-related complications resulting in mortality. CONCLUSION LINAC-based SRS may be considered as a treatment option for high-risk, symptomatic cerebral CM of selected patients with prior bleeding from lesions located at surgically inaccessible or eloquent brain areas.
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Affiliation(s)
- Omer Sager
- Dr. Omer Sager, Department of Radiation Oncology,, Gulhane Military Medical Academy and Medical Faculty,, Ankara 06018, Turkey, T: +903123044683, F: +903123044680,
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29
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Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery 2013; 72:573-89; discussion 588-9. [PMID: 23262564 DOI: 10.1227/neu.0b013e318283c9c2] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cavernous malformations (CMs) in deep locations account for 9% to 35% of brain malformations and are surgically challenging. OBJECTIVE To study the clinical features and outcomes following surgery for deep CMs and the complication of hypertrophic olivary degeneration (HOD). METHODS Clinical records, radiological findings, operative details, and complications of 176 patients with deep CMs were reviewed retrospectively. RESULTS Of 176 patients with 179 CMs, 136 CMs were in the brainstem, 27 in the basal ganglia, and 16 in the thalamus. Cranial nerve deficits (51.1%), hemiparesis (40.9%), numbness (34.7%), and cerebellar symptoms (38.6%) presented most commonly. Hemorrhage presented in 172 patients (70 single, 102 multiple). The annual retrospective hemorrhage rate was 5.1% (assuming CMs are congenital with uniform hemorrhage risk throughout life); the rebleed rate was 31.5%/patient per year. Surgical approach depended on the proximity of the CM to the pial or ependymal surface. Postoperatively, 121 patients (68.8%) had no new neurological deficits. Follow-up occurred in 170 patients. Delayed postoperative HOD developed in 9/134 (6.7%) patients with brainstem CMs. HOD occurred predominantly following surgery for pontine CMs (9/10 patients). Three patients with HOD had palatal myoclonus, nystagmus, and oscillopsia, whereas 1 patient each had limb tremor and hemiballismus. At follow-up, 105 patients (61.8%) improved, 44 (25.9%) were unchanged, and 19 (11.2%) worsened neurologically. Good preoperative modified Rankin Score (98.2% vs 54.5%, P = .001) and single hemorrhage (89% vs 77.3%, P < .05) were predictive of good long-term outcome. CONCLUSION Symptomatic deep CMs can be resected with acceptable morbidity and outcomes. Good preoperative modified Rankin Score and single hemorrhage are predictors of good long-term outcome.
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Affiliation(s)
- Paritosh Pandey
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
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Gross BA, Du R. Diagnosis and Treatment of Vascular Malformations of the Brain. Curr Treat Options Neurol 2013; 16:279. [PMID: 24318447 DOI: 10.1007/s11940-013-0279-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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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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Symptomatic cavernous malformations of the brainstem: functional outcome after microsurgical resection. J Neurol 2013; 260:2815-22. [PMID: 23974645 DOI: 10.1007/s00415-013-7071-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/05/2013] [Accepted: 08/06/2013] [Indexed: 10/26/2022]
Abstract
Brainstem cavernous malformations are associated with a considerable risk of hemorrhage and subsequent morbidity. This study provides a detailed work-up of clinical and radiological outcome as well as identification of prognostic factors in patients who had suffered from symptomatic hemorrhages. Patients who had undergone surgery of symptomatic BSCMs were evaluated pre- and postoperatively both neurologically and neuroradiologically supplemented by telephone interviews. Additionally, patients were scored according to the Scandinavian Stroke Scale. Multiple uni- and multivariate analyses of possible clinical and radiological prognostic factors were conducted. The study population comprised 35 patients. Mean age at operation was 39.3 ± 13.0 years with microsurgical resection of a total of 37 different BSCMs between 2002 and 2011. Median clinical follow-up was 44.0 months (range 8-116 months). Postoperative MRI showed eventually complete resection of all BSCMs. Postoperative overall outcome revealed complete resolution of neurological symptoms for 5/35 patients, 14/35 improved and 9/35 remained unchanged. 7/35 suffered from a postoperative new and permanent neurological deficit, mostly affecting the facial nerve or hemipareses with mild impairment. Pre- and postoperative Scandinavian Stroke Scale scores were 11.0 ± 2.4 and 11.4 ± 2.2 (p = 0.55). None of the analyzed factors were found to significantly correlate with patients' clinical outcome. Complete resection of brainstem cavernous malformations can be achieved with an acceptable risk for long-term morbidity and surgery-related new deficits (~20 %). Neurological outcome is mainly determined within the first 6 months after surgery. Surgical treatment of brainstem cavernous malformations is recommended in symptomatic patients, in whom the lesion is accessible for surgery.
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Abstract
Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. However, there is now sufficient evidence supporting the use of SRS for the difficult cases. Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.
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Cavernous Malformations of the Thalamus: A Relatively Rare but Controversial Entity. World Neurosurg 2013; 79:641-4. [DOI: 10.1016/j.wneu.2012.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 04/24/2012] [Indexed: 11/22/2022]
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Li D, Zhang J, Hao S, Tang J, Xiao X, Wu Z, Zhang L. Surgical Treatment and Long-Term Outcomes of Thalamic Cavernous Malformations. World Neurosurg 2013; 79:704-13. [DOI: 10.1016/j.wneu.2012.01.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 11/22/2011] [Accepted: 01/20/2012] [Indexed: 10/14/2022]
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Royo A, Utrilla C, Carceller F. Surgical Management of Brainstem-Expanding Lesions: The Role of Neuroimaging. Semin Ultrasound CT MR 2013; 34:153-73. [DOI: 10.1053/j.sult.2013.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bertalanffy H, Gerganov VM. Microsurgical or radiosurgical management of intracranial cavernomas. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 116:103-6. [PMID: 23417466 DOI: 10.1007/978-3-7091-1376-9_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cranial cavernous malformations (CCMs) constitute a heterogeneous group of lesions that tend to change dynamically over time with related periods of repeated exacerbation and alternating periods of remission. The decision on their management is based on estimating the inherent risk of further morbidity and the risk/benefit related to the particular treatment mode. Incidentally detected CCMs or lesions in asymptomatic patients presenting without major hemorrhage are best followed up. Complete resection of a CCM is the only healing option and is indicated for symptomatic or hemorrhagic lesions. In the large published series 83-92 % of the patients improved or remained unchanged after surgery, with only 8-11 % showing significant deterioration. For most patients, quality of life is improved. Analysis of the risk/benefit ratio for radiosurgery shows that it should not be regarded as an alternative option: It confers limited protection against bleeding and is related to a certain morbidity risk. In the subgroup of patients with symptomatic or hemorrhagic CCMs in locations that preclude surgical resection with acceptable risks, we recommend follow-up. The senior author is following a group of more than 80 such patients, and the vast majority remain free of hemorrhage and symptoms.
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Affiliation(s)
- Helmut Bertalanffy
- Department of Neurosurgery, International Neuroscience Institute, Rudolf Pichlmayrstr. 4, 30625, Hannover, Germany
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Liscak R, Urgosik D, Simonova G, Vymazal J, Semnicka J. Gamma knife radiosurgery of brain cavernomas. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 116:107-11. [PMID: 23417467 DOI: 10.1007/978-3-7091-1376-9_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Radiosurgery of cavernomas should prevent rebleeding, growth of the lesion, and deterioration of clinical symptoms. However, there is no direct diagnostic tool to verify the endpoints of treatment. At present, the positive effects of radiosurgery are identified by clinical observation and analysis of imaging changes on magnetic resonance imaging during a sufficiently long follow-up period. METHODS Between 1992 and 2000, a total of 112 patients with brain cavernomas were treated with Gamma Knife radiosurgery at our center. In all, 59 patients experienced bleeding before radiosurgery; the remainder did not. The median age of patients was 42 years, the median volume of the cavernomas was 0.9 cm(3), and the median applied marginal dose was 16 Gy. RESULTS After a 2-year latent interval after treatment (median follow-up 84 months), the risk of bleeding in the group of patients with bleeding before radiosurgery had decreased from 3.7 % to 0.2 %. For the patients without bleeding before radiosurgery, the annual risk of bleeding was 0.8 %. The cavernoma size decreased in 53.0 % of cases and increased in 6.4 %. Epilepsy, if present before the treatment, was alleviated in 45 % of cases. The risks of temporary or permanent morbidity caused by radiosurgery were 14.6 % and 0.9 %, respectively. CONCLUSION Radiosurgery of cavernomas was associated with a low risk of permanent morbidity. The risk of rebleeding after the 2-year latent interval after radiosurgery had decreased. Treatment of cavernomas with no history of bleeding was halted at our center.
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Affiliation(s)
- Roman Liscak
- Hospital Na Homolce, Roentgenova 2, Prague, 150 30, Czech Republic.
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de Aguiar PHP, Zicarelli CAM, Isolan G, Antunes A, Aires R, Georgeto SM, Tahara A, Haddad F. Brainstem cavernomas: a surgical challenge. EINSTEIN-SAO PAULO 2012; 10:67-73. [PMID: 23045829 DOI: 10.1590/s1679-45082012000100014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. METHODS From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. RESULTS The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. CONCLUSIONS Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.
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Park SH, Hwang SK. Gamma knife radiosurgery for symptomatic brainstem intra-axial cavernous malformations. World Neurosurg 2012; 80:e261-6. [PMID: 23010066 DOI: 10.1016/j.wneu.2012.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/31/2012] [Accepted: 09/15/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and safety of gamma knife radiosurgery (GKRS) for the treatment of symptomatic brainstem intra-axial cavernous malformations (CMs) associated with high surgical morbidity. METHODS Twenty-one patients with symptomatic brainstem intra-axial CMs were treated by GKRS between 2005 and 2010. One patient was lost to follow-up. The median age of the patients was 39.5 years (range, 24-69 years). All patients had experienced 1 or more symptomatic hemorrhages before GKRS (range, 1-3). The median marginal radiation dose was 13 Gy, and the median volume of the malformation was 0.56 mL. The median follow-up period after radiosurgery was 32 months (range, 12-82 months; mean, 38.9 months). RESULTS Before GKRS, 31 hemorrhages (1.55 per patient) were observed. The annual hemorrhage rate before GKRS was 39.5%, excluding the first hemorrhage. After GKRS, 1 hemorrhage (0.05 per patient) was identified. It occurred 6 months after radiosurgery. The patient showed complete recovery to a premorbid status with steroid medication. The annual hemorrhage rate after GKRS was 8.2% for the first 2 years. After the expected latency period, no hemorrhages were identified. One patient (5%) exhibited permanent paresthesia, which was a new neurologic symptom in absence of any hemorrhagic event, after the radiosurgery. CONCLUSIONS GKRS seems to be relatively effective and safe for reducing the rebleeding rate of brainstem intra-axial CMs that have high surgical risk. Careful selection of a low marginal dose and an optimal radiosurgical technique are helpful to achieve good outcomes.
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Affiliation(s)
- Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea.
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Batra S, Rigamonti K, Rigamonti D. Management of Hemorrhage from Cavernous Malformations. Curr Atheroscler Rep 2012; 14:360-5. [DOI: 10.1007/s11883-012-0261-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Fuetsch M, El Majdoub F, Hoevels M, Müller RP, Sturm V, Maarouf M. Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas. Strahlenther Onkol 2012; 188:311-6. [PMID: 22314579 DOI: 10.1007/s00066-011-0050-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 09/15/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of deep-seated cerebral cavernous malformations (CCMs) is still controversial. Although surgery remains the treatment of choice in patients with recurrent hemorrhage, patients with CCMs located in the brainstem are in many cases not eligible for resection due to high procedure-related morbidity and mortality. We evaluated the long-term outcome of LINAC radiosurgery (LINAC-RS) for the treatment of brainstem CCMs. PATIENTS AND METHODS Between December 1992 and March 2008, 14 patients (6 men, 8 women) harboring brainstem CCMs underwent LINAC-RS. Pretreatment neuroimaging showed no associated developmental venous angiomas (DVAs) in any of our patients. Prior to treatment, all patients suffered at least from one symptomatic hemorrhage (median 1.8, range 1–3). A median follow-up of 7.1 years (range 2.0–16.8 years) could be obtained in 12 patients. We applied a median tumor surface dose of 13.9 Gy (range 11–18 Gy; median tumor volume 1.6 ml, range 0.4–4.3 ml). RESULTS Following LINAC-RS, neurological outcome improved in 4 (33.3%) and remained unchanged in 8 patients (66.7%). Rebleeding with subsequent transient neurological status deterioration occurred in 4 patients (33.3%), leading to additional surgical resection in 2 patients (16.7%). The corresponding annual hemorrhage rate was 4.8% (4/82.8 patient–years). Adverse radiation effects (ARE, defined by perilesional hyperintensity on T2-weighted MR images) were revealed in 3 patients (25%), leading to transient neurological deficits in 2 patients (16.7%). There were no procedure-related complications leading to either permanent morbidity or mortality. CONCLUSION Our results support the role of LINAC-RS as an efficient and safe treatment to significantly reduce the annual hemorrhage rate in patients suffering from brainstem CCMs not eligible to microsurgery. Compared with radiosurgery for arteriovenous malformations (AVMs), the intervention-related morbidity is higher.
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Affiliation(s)
- M Fuetsch
- Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne
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Jay SM, Chandran H, Blackburn TPD. Gamma knife stereotactic radiosurgery for thalamic & brainstem cavernous angiomas. Br J Neurosurg 2011; 26:367-70. [PMID: 22149475 DOI: 10.3109/02688697.2011.635819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of Gamma Knife stereotactic radiosurgery (GKS) in the treatment of patients with symptomatic cavernous angiomas (CA) of the brainstem or thalamus, by comparing overall outcome to the natural history of the disease. METHODS Over 10 years a series of 16 consecutively presenting patients (M = 9, F = 7) with thalamic or brainstem CA were treated with GKS to a single lesion, specifically excluding the haemosiderin ring from the target. Within the year prior to treatment eight patients had suffered one symptomatic haemorrhage and eight had suffered more than one symptomatic haemorrhage. Mean age at treatment was 38.9 (15-55) years. Mean prescription dose 13.31 Gray (11.0 Gy-16.0 Gy). Patients were followed up radiologically and, more importantly, clinically for a mean period of 43.8 (11-101) months, median 36 months. RESULTS One patient suffered recurrent haemorrhage at 23 months post-GKS, but has not re-bled in the following 61 months. One patient died of thalamic haemorrhage from the treated lesion at 90 months. One patient was lost to follow up. There have been no other clinical episodes or radiological findings to suggest post-GKS haemorrhage in the remaining 13 patients, and no other complications were observed in the treated population. The annual haemorrhage rate within the first two years post GKS was 3.72% and the annual haemorrhage rate 2 years post GKS was 3.59% per annum. CONCLUSION With the dose regimens described, GKS is safe and effective in the treatment of thalamic and brainstem CA, as assessed by significant reduction in observed rate of re-haemorrhage over that expected from the known natural history of those CAs which have already demonstrated a tendency to haemorrhage in highly eloquent areas.
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Affiliation(s)
- S M Jay
- The London Gamma Knife Centre, St Bartholomew's Hospital, London, UK.
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Chalouhi N, Dumont AS, Randazzo C, Tjoumakaris S, Gonzalez LF, Rosenwasser R, Jabbour P. Management of incidentally discovered intracranial vascular abnormalities. Neurosurg Focus 2011; 31:E1. [DOI: 10.3171/2011.9.focus11200] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With the widespread use of brain imaging studies, neurosurgeons have seen a marked increase in the number of incidental intracranial lesions, including vascular abnormalities. Specifically, the detection of incidentally discovered aneurysms, arteriovenous malformations, cavernous angiomas, developmental venous anomalies, and capillary telangiectasias has increased. The best management strategy for most of these lesions is controversial. Treatment options include observation, open surgery, endovascular procedures, and radiosurgery. Multiple factors should be taken into account when discussing treatment indications, including the natural history of the disease and the risk of the treatment. In this article, the authors focus on the natural history of these lesions and the risk of the treatment, and they give recommendations regarding the most appropriate management strategy based on the current evidence in the literature and their experience with intracranial vascular abnormalities.
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Abstract
Cavernous malformations (CMs) are vascular lesions found in the central nervous system (CNS) and throughout the body and have been called cavernomas, cavernous angiomas, and cavernous hemangiomas. This article discusses the epidemiology, natural history, diagnosis, treatment and follow-up of children who are found to harbor these lesions. CMs affect children by causing hemorrhage, seizure, focal neurologic deficits, and headache. Diagnosis is best made with magnetic resonance imaging. Patients with multiple lesions should be referred for genetic evaluation and counseling. Individuals with symptomatic, growing, or hemorrhagic malformations should be considered for surgical resection. Close follow-up after diagnosis and treatment is helpful to identify lesion progression or recurrence.
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Affiliation(s)
- Edward R Smith
- Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Abstract
Over the last 2 decades, there have been dramatic advancements in our understanding of and the ability to treat brainstem cavernous malformations (BCMs). Once thought untreatable, BCMs are now being more aggressively and safely treated microsurgically as a result of advances in monitoring and imaging technologies, as well as refinement of surgical techniques. BCMs deemed inoperable are being treated with radiosurgery, and experience with dosing and targeting has improved the safety of this treatment modality as well. Much work remains to be done, and prospective randomized trials would undoubtedly further existing knowledge.
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Affiliation(s)
- Edward A M Duckworth
- Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden Road, Suite 750, Houston, TX 77030, USA.
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Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to brainstem cavernous malformations. Neurosurg Focus 2010; 29:E8. [PMID: 20809766 DOI: 10.3171/2010.6.focus10128] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brainstem cavernous malformations (CMs) are low-flow vascular lesions in eloquent locations. Their presentation is often marked with symptomatic hemorrhages that appear to occur more frequently than hemorrhage from supratentorial cavernomas. Brainstem CMs can be removed using 1 of the 5 standard skull-base approaches: retrosigmoid, suboccipital (with or without telovelar approach), supracerebellar infratentorial, orbitozygomatic, and far lateral. Patients being referred to a tertiary institution often have lesions that are aggressive with respect to bleeding rates. Nonetheless, the indications for surgery, in the authors' opinion, are the same for all lesions: those that are symptomatic, those that cause mass effect, or those that abut a pial surface. Patients often have relapsing and remitting courses of symptoms, with each hemorrhage causing a progressive and stepwise decline. Many patients experience new postoperative deficits, most of which are transient and resolve fully. Despite the risks associated with operating in this highly eloquent tissue, most patients have had favorable outcomes in the authors' experience. Surgical treatment of brainstem CMs protects patients from the potentially devastating effects of rehemorrhage, and the authors believe that the benefits of intervention outweigh the risks in patients with the appropriate indications.
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Affiliation(s)
- Adib A Abla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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