1
|
Li Z, Lu J, Liu M, Ma L, Quan K, Zhang H, Liu P, Shi Y, Dong X, You C, Tian R, Zhu W. Development and Validation of a Supplementary Grading Scale for Outcomes of Brainstem Cavernous Malformations. Stroke 2024; 55:1991-2002. [PMID: 38881452 DOI: 10.1161/strokeaha.123.045943] [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] [Received: 11/21/2023] [Accepted: 05/21/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Surgical risk assessment is intriguing for clinical decision-making of brainstem cavernous malformation (BSCM) treatment. While the BSCM grading scale, encompassing size, developmental venous anomaly, crossing axial midpoint, age, and timing of intervention, is increasingly utilized, the clinical relevance of neurological fluctuation and recurrent hemorrhage has not been incorporated. This study aimed to propose a supplementary grading scale with enhanced predictive efficacy. METHODS Using a retrospective nationwide registry of consecutive patients with BSCMs undergoing surgery in China from March 2011 to May 2023, a new supplementary BSCM grading scale was developed from a derivative cohort of 260 patients and validated in an independent concurrent cohort of 67 patients. The primary outcome was unfavorable neurological function (modified Rankin Scale score >2) at the latest follow-up. The performance of the supplementary grading system was evaluated for discrimination, calibration, and clinical utility and further compared with its original counterpart. RESULTS Over a follow-up of at least 6 months after surgery, the unfavorable outcomes were 31% in the overall cohort (101/327 patients). A preoperative motor deficit (odds ratio, 3.13; P=0.001), recurrent hemorrhage (odds ratio, 3.05; P<0.001), timing of intervention (odds ratio, 7.08; P<0.001), and crossing the axial midpoint (odds ratio, 2.57; P=0.006) were associated with the unfavorable outcomes and composed the initial Huashan grading variables. A supplementary BSCM grading system was subsequently developed by incorporating the Huashan grading variables into the original BSCM grading scale. The predictive capability of the supplementary scale was consistently superior to the original counterpart in either the derivative cohort (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.68-0.80] for the supplementary versus 0.68 [95% CI, 0.61-0.74] for the original) or the validation cohort (0.75 [95% CI, 0.62-0.87] versus 0.64 [95% CI, 0.48-0.81]). CONCLUSIONS This study highlights the neurological relevance of BSCM hemorrhage in surgical risk assessment. Via compositing preoperative motor function and recurrent hemorrhages, a supplementary grading scale may improve a dynamic risk assessment for clinical decisions in the management of BSCMs.
Collapse
Affiliation(s)
- Zongze Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu (J.L., C.Y., R.T.)
| | - Mingjian Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, PA (L.M.)
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Hongfei Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Xuchen Dong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu (J.L., C.Y., R.T.)
| | - Rui Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu (J.L., C.Y., R.T.)
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- National Center for Neurological Disorders, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Neurosurgical Institute of Fudan University, Shanghai, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
- Shanghai Clinical Medical Center of Neurosurgery, China (Z.L., M.L., K.Q., H.Z., P.L., Y.S., X.D., W.Z.)
| |
Collapse
|
2
|
Li Z, Lu J, Liu M, Ma L, Quan K, Zhang H, Liu P, Shi Y, Dong X, You C, Tian R, Zhu W. Association of hemorrhage-to-treatment time with outcomes in patients with brainstem cavernous malformations: a nationwide cohort study. Int J Surg 2024; 110:2217-2225. [PMID: 38668661 PMCID: PMC11020047 DOI: 10.1097/js9.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/09/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Brainstem cavernous malformations (BSCMs) often present with haemorrhage, but the optimal timing for microsurgical intervention remains unclear. This study aims to explore how intervention timing relates to neurological outcomes in haemorrhagic BSCM patients undergoing microsurgery, offering insights for clinical decisions. METHODS A total of 293 consecutive patients diagnosed with BSCMs, who underwent microsurgery were identified between March 2011 and January 2023 at two comprehensive centres in China, with a postoperative follow-up duration exceeding 6 months. Utilizing logistic regression models with restricted cubic splines, distinct time groups were identified. Subsequently, matching weight analysis compared these groups in terms of outcomes, new haemorrhage rates, cranial nerve deficits, and perioperative complications. The primary outcome was an unfavourable outcome, which was defined as a mRS score greater than 2 at the latest follow-up. RESULTS Among the 293 patients, 48.5% were female, median age was (39.9±14.3) years, and median haemorrhage-to-treatment time was 42 days. Patients were categorized into acute (≤21 days), subacute (22-42 days), and delay (>42 days) intervention groups. After matching, 186 patients were analyzed. Adjusted analysis showed lower unfavourable outcome rates for acute [adjusted odds ratio (OR), 0.73; 95% CI, 0.65-0.82; P<0.001] and subacute (adjusted OR, 0.83; 95% CI, 0.72-0.95; P=0.007) groups compared to the delay group. Subacute intervention led to fewer cranial nerve deficits (adjusted OR, 0.76; 95% CI, 0.66-0.88, P<0.001). New haemorrhage incidence didn't significantly differ among groups. CONCLUSIONS For haemorrhagic BSCMs patients, delayed microsurgical intervention that exceeded 42 days after a prior haemorrhage were associated with an increased risk of unfavourable neurological outcomes.
Collapse
Affiliation(s)
- Zongze Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingjian Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Hongfei Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Xuchen Dong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University
- Shanghai Clinical Medical Center of Neurosurgery. Shanghai
| |
Collapse
|
3
|
Albalkhi I, Shafqat A, Bin-Alamer O, Mallela AN, Kuminkoski C, Labib MA, Lang MJ, Lawton MT, Morcos JJ, Couldwell WT, Abou-Al-Shaar H. Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:252. [PMID: 37726558 DOI: 10.1007/s10143-023-02152-8] [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] [Received: 08/09/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35 years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58 months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.
Collapse
Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chloe Kuminkoski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jacques J Morcos
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
6
|
Benner D, Hendricks BK, Benet A, Graffeo CS, Scherschinski L, Srinivasan VM, Catapano JS, Lawrence PM, Schornak M, Lawton MT. A system of anatomical triangles defining dissection routes to brainstem cavernous malformations: definitions and application to a cohort of 183 patients. J Neurosurg 2023; 138:768-784. [PMID: 36029260 DOI: 10.3171/2022.6.jns212907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anatomical triangles defined by intersecting neurovascular structures delineate surgical routes to pathological targets and guide neurosurgeons during dissection steps. Collections or systems of anatomical triangles have been integrated into skull base surgery to help surgeons navigate complex regions such as the cavernous sinus. The authors present a system of triangles specifically intended for resection of brainstem cavernous malformations (BSCMs). This system of triangles is complementary to the authors' BSCM taxonomy that defines dissection routes to these lesions. METHODS The anatomical triangle through which a BSCM was resected microsurgically was determined for the patients treated during a 23-year period who had both brain MRI and intraoperative photographs or videos available for review. RESULTS Of 183 patients who met the inclusion criteria, 50 had midbrain lesions (27%), 102 had pontine lesions (56%), and 31 had medullary lesions (17%). The craniotomies used to resect these BSCMs included the extended retrosigmoid (66 [36.1%]), midline suboccipital (46 [25.1%]), far lateral (30 [16.4%]), pterional/orbitozygomatic (17 [9.3%]), torcular (8 [4.4%]), and lateral suboccipital (8 [4.4%]) approaches. The anatomical triangles through which the BSCMs were most frequently resected were the interlobular (37 [20.2%]), vallecular (32 [17.5%]), vagoaccessory (30 [16.4%]), supracerebellar-infratrochlear (16 [8.7%]), subtonsillar (14 [7.7%]), oculomotor-tentorial (11 [6.0%]), infragalenic (8 [4.4%]), and supracerebellar-supratrochlear (8 [4.4%]) triangles. New but infrequently used triangles included the vertebrobasilar junctional (1 [0.5%]), supratrigeminal (3 [1.6%]), and infratrigeminal (5 [2.7%]) triangles. Overall, 15 BSCM subtypes were exposed through 6 craniotomies, and the approach was redirected to the BSCM by one of the 14 triangles paired with the BSCM subtype. CONCLUSIONS A system of BSCM triangles, including 9 newly defined triangles, was introduced to guide dissection to these lesions. The use of an anatomical triangle better defines the pathway taken through the craniotomy to the lesion and refines the conceptualization of surgical approaches. The triangle concept and the BSCM triangle system increase the precision of dissection through subarachnoid corridors, enhance microsurgical execution, and potentially improve patient outcomes.
Collapse
Affiliation(s)
- Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Benjamin K. Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S. Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Lea Scherschinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Peter M. Lawrence
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Mark Schornak
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
7
|
Li Z, Ma L, Quan K, Liu P, Shi Y, Liu Y, Zhu W. Rehemorrhage of brainstem cavernous malformations: a benchmark approach to individualized risk and severity assessment. J Neurosurg 2022:1-12. [PMID: 36585870 DOI: 10.3171/2022.11.jns222277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/29/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) represent a unique subgroup of cavernous malformations with more hemorrhagic presentation and technical challenges. This study aimed to provide individualized assessment of the rehemorrhage clustering risk of BSCMs after the first symptomatic hemorrhage and to identify patients at higher risk of neurological deterioration after new hemorrhage, which would help in clinical decision-making. METHODS A total of 123 consecutive BSCM patients with symptomatic hemorrhage were identified between 2015 and 2022, with untreated follow-up > 12 months or subsequent hemorrhage during the untreated follow-up. Nomograms were proposed to individualize the assessment of subsequent hemorrhage risk and neurological status (determined by the modified Rankin Scale [mRS] score) after future hemorrhage. The least absolute shrinkage and selector operation (LASSO) regression was used for feature screening. The calibration curve and concordance index (C-index) were used to assess the internal calibration and discrimination performance of the nomograms. Cross-validation was further performed to validate the accuracy of the nomograms. RESULTS Prior hemorrhage times (adjusted OR [aOR] 6.78 per ictus increase) and Zabramski type I or V (OR 11.04) were associated with rehemorrhage within 1 year. A lower mRS score after previous hemorrhage (aOR 0.38 for a shift to a higher mRS score), Zabramski type I or V (OR 3.41), medulla or midbrain location (aOR 2.77), and multiple cerebral cavernous malformations (aOR 11.76) were associated with worsened neurological status at subsequent hemorrhage. The nomograms showed good accuracy and discrimination, with a C-index of 0.80 for predicting subsequent hemorrhage within 1 year and 0.71 for predicting neurological status after subsequent hemorrhage, which were maintained in cross-validation. CONCLUSIONS An individualized approach to risk and severity assessment of BSCM rehemorrhage was feasible with clinical and imaging features.
Collapse
Affiliation(s)
- Zongze Li
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Li Ma
- 6Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kai Quan
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Peixi Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yuan Shi
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Yingjun Liu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Wei Zhu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai.,2National Center for Neurological Disorders, Shanghai.,3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai.,4Neurosurgical Institute of Fudan University, Shanghai.,5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| |
Collapse
|
8
|
Catapano JS, Benner D, Rhodenhiser EG, Rumalla K, Graffeo CS, Srinivasan VM, Winkler EA, Lawton MT. Safety of brainstem safe entry zones: comparison of microsurgical outcomes associated with superficial, exophytic, and deep brainstem cavernous malformations. J Neurosurg 2022:1-11. [PMID: 36681989 DOI: 10.3171/2022.9.jns222012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Safe entry zones (SEZs) enable safe tissue transgression to lesions beneath the brainstem surface. However, evidence for the safety of SEZs is scarce and is based on anatomical studies, case reports, and small series. METHODS A cohort of 154 patients who underwent microsurgical brainstem cavernous malformation (BSCM) treatment during a 23-year period and who had preoperative MR images and intraoperative photographs or videos was retrospectively examined. This study assessed the safety of SEZs for access to deep BSCMs, preoperative MRI to predict BSCM surface proximity, and the relationships between BSCM subtype, surgical approach, and SEZs. Lesions were characterized as exophytic, superficial, or deep on the basis of preoperative MRI and intraoperative inspection. Outcomes were scored as good (modified Rankin Scale [mRS] score ≤ 2) or poor (mRS score > 2) and relative outcomes as stable/improved or worse relative to baseline (± 1 point). RESULTS Resections included 34 (22%) in the midbrain, 102 (66%) in the pons, and 18 (12%) in the medulla. Of those, 23 (15%) were exophytic, 57 (37%) were superficial, and 74 (48%) were deep. Established SEZs were used for 97% (n = 72) of deep lesions; the preferred SEZ associated with its subtype was used for 91% (n = 67). MR images accurately depicted exophytic BSCMs that did not require SEZ approaches (sensitivity, 96%) but overestimated the proximity of lesions superficial to brainstem surfaces (specificity, 67%), resulting in unanticipated SEZ use. Final neurological outcomes were good in 80% of patients with follow-up data (119/149), and relative outcomes were stable/improved in 93% (139/149). Outcomes for patients with brainstem transgression through an SEZ did not differ from outcomes for patients with superficial or exophytic lesions that did not require SEZ use (final mRS score ≤ 2 in 72% of all patients with deep lesions vs 82% of all patients with superficial or exophytic lesions [p = 0.10]). Among patients with follow-up, the rates of permanent new cranial nerve deficits in patients with deep BSCMs and superficial or exophytic BSCMs were 21% and 20%, respectively (p = 0.81), with no significant change in overall cranial nerve deficit (0 and -1, p = 0.65). CONCLUSIONS Neurological outcomes for patients with deep BSCMs were equivalent to those for superficial or exophytic BSCMs, validating the safety of SEZs for deep BSCMs. Preoperative T1-weighted MR images overestimated the lesion's surface proximity, necessitating detailed knowledge of SEZs and readiness to use them in cases of radiological-microsurgical discordance. Most patients achieved favorable outcomes despite the transgression of eloquent brainstem tissue in and around SEZs.
Collapse
Affiliation(s)
- Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Emmajane G. Rhodenhiser
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Christopher S. Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Ethan A. Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|