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Kuroedov D, Cunha B, Pamplona J, Castillo M, Ramalho J. Cerebral cavernous malformations: Typical and atypical imaging characteristics. J Neuroimaging 2023; 33:202-217. [PMID: 36456168 DOI: 10.1111/jon.13072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
Cavernous malformations (CMs) are benign vascular malformations that maybe seen anywhere in the central nervous system. They are dynamic lesions, growing or shrinking over time and only rarely remaining stable. Size varies from a few millimeters to a few centimeters. CMs can be sporadic or familial, and while most of them are congenital, de novo and acquired lesions may also be seen. Etiology is still unknown. A genetic molecular mechanism has been proposed since a cerebral cavernous malformation gene loss of function was found in both familial and sporadic lesions. Additionally, recent studies suggest that formation of CMs in humans may be associated with a distinctive bacterial gut composition (microbioma). Imaging is fairly typical but may vary according to age, location, and etiology. Follow-up is not well established because CMs patients have a highly unpredictable clinical course. Angiogenic and inflammatory mechanisms have been implicated in disease activity, as well as lesional hyperpermeability and iron deposition. Imaging and serum biomarkers of these mechanisms are under current investigation. Treatment options, including surgery or radiosurgery, are not well defined and are dependent upon multiple factors, including clinical presentation, lesion location, number of hemorrhagic events, and medical comorbidities. Our purpose is to review the imaging features of CMs based on their size, location, and etiology, as well as their differential diagnosis and best imaging approach. New insights in etiology will be briefly considered. Follow-up strategies, including serum and imaging biomarkers, and treatment options will also be discussed.
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Affiliation(s)
- Danila Kuroedov
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Bruno Cunha
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jaime Pamplona
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Mauricio Castillo
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Joana Ramalho
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
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2
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Earlier Age at Surgery for Brain Cavernous Angioma-Related Epilepsy May Achieve Complete Seizure Freedom without Aid of Anti-Seizure Medication. Brain Sci 2022; 12:brainsci12030403. [PMID: 35326359 PMCID: PMC8946282 DOI: 10.3390/brainsci12030403] [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: 03/01/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
Background: The present study hypothesized that some factors may distinguish between patients with a brain cavernous angioma (BCA), who were free from anti-seizure medication (ASM), and patients who still required ASMs postoperatively. The purpose of the study was thus to identify factors associated with ceasing ASMs for patients with drug-resistant epilepsy secondary to BCA, who underwent BCA removal surgery. Methods: We divided patients into those with drug-resistant epilepsy secondary to BCA who achieved complete seizure freedom without ASMs a year after surgery (No-ASM group) (International League Against Epilepsy (ILAE) classification class I with no epileptiform discharges), and others (ASM group) (ILAE classification ≤ II and/or epileptiform discharges). We statistically compared groups in terms of: (1) age at operation; (2) history of epilepsy; (3) size of BCA; and (4) location of BCA. Results: Overall, a year after the surgery, the No-ASM group comprised 12 patients (48%), and the ASM group comprised 13 patients (52%). In both multi- and univariate logistic regression analyses, age at BCA removal surgery correlated significantly with the No-ASM group (p = 0.043, p = 0.019), but history of epilepsy did not (p = 0.581, p = 0.585). Conclusions: Earlier age at surgery for patients with drug-resistant epilepsy is encouraged to achieve complete seizure freedom without the need for ASMs when the cause of epilepsy is BCA.
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3
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Samadian M, Maroufi SF, Bakhtevari MH, Borghei-Razavi H. An isolated cavernous malformation of the sixth cranial nerve: A case report and review of literature. Surg Neurol Int 2021; 12:563. [PMID: 34877049 PMCID: PMC8645491 DOI: 10.25259/sni_811_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/07/2021] [Indexed: 11/04/2022] Open
Abstract
Background Isolated cavernous malformation (CM) of the abducens nerve has not been reported in the literature. Herein, the authors address the clinical importance of these lesions and review the reported cases of CM from 2014 to 2020. Case Description A 21-year-old man presented with binocular diplopia and headache from 2 months before his admission. The neurological examination revealed right-sided abducens nerve palsy. The brain MRI revealed an extra-axial pontomedullary lesion suggestive of a CM. The lesion was surgically removed. During the operation, the abducens nerve was resected considering the lesion could not be separated from the nerve and an anastomosis was performed using an interposition nerve graft and fibrin glue. Pathological examination of the resected lesion revealed that it was originated from within the nerve. The patient's condition improved in postoperative follow-ups. Conclusion Surgical resection of the cranial nerves CMs is appropriate when progressive neurological deficits are present. If the lesion is originated from within the nerve, we suggest resection of the involved nerve and performing anastomosis. Novel MRI sequences might help surgeons to be prepared for such cases and fibrin glue can serve as an appropriate tool to perform anastomosis when end-to-end sutures are impossible to perform.
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Affiliation(s)
- Mohammad Samadian
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Faculty of Medicine, Tehran University of Medical Sciences, Valiasr, Tehran, Iran
| | | | - Hamid Borghei-Razavi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic-Taussig Cancer Center, Cleveland, Ohio, United States
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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5
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The brainstem and its neurosurgical history. Neurosurg Rev 2021; 44:3001-3022. [PMID: 33580370 DOI: 10.1007/s10143-021-01496-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
Brainstem is one of the most complex structures of the human body, and has the most complex intracranial anatomy, which makes surgery at this level the most difficult. Due to its hidden position, the brainstem became known later by anatomists, and moreover, brainstem surgery cannot be understood without knowing the evolution of ideas in neuroanatomy, neuropathology, and neuroscience. Starting from the first attempts at identifying brainstem anatomy in prehistory and antiquity, the history of brainstem discoveries and approach may be divided into four periods: macroscopic anatomy, microscopic anatomy and neurophysiology, posterior fossa surgery, and brainstem surgery. From the first trepanning of the posterior fossa and later finger surgery, to the occurrence of safe entry zones, this paper aims to review how neuroanatomy and brainstem surgery were understood historically, and how the surgical technique evolved from Galen of Pergamon up to the twenty-first century.
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6
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Rennert RC, Hoshide R, Calayag M, Kemp J, Gonda DD, Meltzer HS, Fukushima T, Day JD, Levy ML. Extended middle fossa approach to lateralized pontine cavernomas in children. J Neurosurg Pediatr 2018; 21:384-388. [PMID: 29393814 DOI: 10.3171/2017.10.peds17381] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of hemorrhagic cavernous malformations within the lateral pontine region demands meticulous surgical planning and execution to maximize resection while minimizing morbidity. The authors report a single institution's experience using the extended middle fossa rhomboid approach for the safe resection of hemorrhagic cavernomas involving the lateral pons. METHODS A retrospective chart review was performed to identify and review the surgical outcomes of patients who underwent an extended middle fossa rhomboid approach for the resection of hemorrhagic cavernomas involving the lateral pons during a 10-year period at Rady Children's Hospital of San Diego. Surgical landmarks for this extradural approach were based on the Fukushima dual-fan model, which defines the rhomboid based on the following anatomical structures: 1) the junction of the greater superficial petrosal nerve (GSPN) and mandibular branch of the trigeminal nerve; 2) the lateral edge of the porus trigeminus; 3) the intersection of the petrous ridge and arcuate eminence; and 4) the intersection of the GSPN, geniculate ganglion, and arcuate eminence. The boundaries of maximal bony removal for this approach are the clivus inferiorly below the inferior petrosal sinus; unroofing of the internal auditory canal posteriorly; skeletonizing the geniculate ganglion, GSPN, and internal carotid artery laterally; and drilling under the Gasserian ganglion anteriorly. This extradural petrosectomy allowed for an approach to all lesions from an area posterolateral to the basilar artery near its junction with cranial nerve (CN) VI, superior to the anterior inferior cerebellar artery and lateral to the origin of CN V. Retraction of the mandibular branch of the trigeminal nerve during this approach allowed avoidance of the region involving CN IV and the superior cerebellar artery. RESULTS Eight pediatric patients (4 girls and 4 boys, mean age of 13.2 ± 4.6 years) with hemorrhagic cavernomas involving the lateral pons and extension to the pial surface were treated using the surgical approach described above. Seven cavernomas were completely resected. In the eighth patient, a second peripheral lesion was not resected with the primary lesion. One patient had a transient CN VI palsy, and 2 patients had transient trigeminal hypesthesia/dysesthesia. One patient experienced a CSF leak that was successfully treated by oversewing the wound. CONCLUSIONS The extended middle fossa approach can be used for resection of lateral pontine hemorrhagic cavernomas with minimal morbidity in the pediatric population.
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Affiliation(s)
- Robert C Rennert
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | - Reid Hoshide
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | - Mark Calayag
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | - Joanna Kemp
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | - David D Gonda
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | - Hal S Meltzer
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
| | | | - John D Day
- 3Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Michael L Levy
- 1Department of Pediatric Neurosurgery, University of California, San Diego, California
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7
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Abstract
Cavernous malformations, accounting for approximately 5-15% of all vascular abnormalities in the central nervous system, are angiographically occult lesions which most often present with seizures, rather than acute hemorrhage. Widely variable across populations, the incidence of cavernous malformations has been reported to be 0.15-0.56 per 100 000 persons per year, with an annual hemorrhage rate of 0.6-11% per patient-year. Seen in 0.17-0.9% of the population, up to one-half are familial, and at least three gene loci have been associated with a familial form, more common among Hispanic Americans. Most cavernous malformations are supratentorial, with 10-23% in the posterior fossa, and approximately 5% found in the spine.
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Affiliation(s)
- Hannah E Goldstein
- Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, NY, USA
| | - Robert A Solomon
- Department of Neurosurgery, The Neurological Institute, Columbia University Medical Center, New York, NY, USA.
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8
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Affiliation(s)
- A. Valavanis
- Abteilung für Neuroradiologie, Universitätsspital; Zürich
| | - S. Schefer
- Abteilung für Neuroradiologie, Universitätsspital; Zürich
| | - W. Wichmann
- Abteilung für Neuroradiologie, Universitätsspital; Zürich
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9
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Abstract
ABSTRACT:We report experience with 11 patients misdiagnosed for years, on the basis of computed tomography (CT) and angiography, as harbouring brainstem tumours in whom magnetic resonance imaging (MRI) demonstrated cavernous angiomas. Seven had undergone external irradiation, 2 had a ventriculo-peritoneal shunt, 2 developed aseptic femur necrosis following corticosteroid treatment, 1 had undergone a biopsy with a pathological diagnosis of glioma. CT had depicted ill-defined, hyperdense, faintly enhancing lesions. Angiography was normal, or showed an avascular mass or subtle venous pooling. MRI delineated discrete lesions, typical of cavernous angiomas, with a mixed hyperintense, reticulated, central core surrounded by a hypointense rim. Six patients subsequently underwent stereotactic radiosurgery without changes in clinical status or lesion. Although hemorrhagic neoplasms may mimic the clinical course and MRI appearance of cavernous angiomas, MRI is useful in the diagnosis of brainstem cavernous angiomas and should be performed in patients with suspected brainstem tumours.
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10
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Almeida JP, Medina R, Tamargo RJ. Management of posterior fossa arteriovenous malformations. Surg Neurol Int 2015; 6:31. [PMID: 25745586 PMCID: PMC4348799 DOI: 10.4103/2152-7806.152140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/20/2014] [Indexed: 11/28/2022] Open
Abstract
Background: Posterior fossa arteriovenous malformations (AVMs) are rare vascular lesions, representing 7–15% of all intracranial AVMs. Although less frequent than supratentorial AVMs, they present higher rupture, morbidity, and mortality rates. Microsurgery, radiosurgery, and endovascular neurosurgery are treatment options for obliteration of those lesions. In this paper, we present a critical review of the literature about the management of posterior fossa AVM. Methods: A MEDLINE-based search of articles published between January 1960 and January 2014 was performed. The search terms: “Posterior fossa arteriovenous malformation,” “microsurgery,” “radiosurgery,” and “endovascular” were used to identify the articles. Results: Current data supports the role of microsurgery as the gold standard treatment for cerebellar AVMs. Brainstem AVMs are usually managed with radiotherapy and endovascular therapy; microsurgery is considered in cases of pial brainstem AVMs. Conclusions: Succsseful treatment of posterior fossa AVMs depend on an integrated work of neurosurgeons, radiosurgeons, and endovascular neurosurgery. Although the development of radiosurgery and endovascular techniques is remarkable, microsurgery remains as the gold standard treatment for most of those lesions.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Roberto Medina
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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11
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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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12
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Thines L, Dehdashti AR, da Costa L, Tymianski M, ter Brugge KG, Willinsky RA, Schwartz M, Wallace MC. Challenges in the Management of Ruptured and Unruptured Brainstem Arteriovenous Malformations: Outcome After Conservative, Single-Modality, or Multimodality Treatments. Neurosurgery 2011; 70:155-61; discussion 161. [DOI: 10.1227/neu.0b013e31822670ac] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Brainstem arteriovenous malformations are challenging lesions, and benefits of treatment are uncertain.
OBJECTIVE
To study the clinical course of Brainstem arteriovenous malformations and the influence of treatments on outcome.
METHODS
We reviewed a prospective series of 31 brainstem arteriovenous malformations. Demographic, morphological, and clinical characteristics were recorded. Factors determining initial and final outcomes (modified Rankin Scale), results of treatments (cure rates, complications), and disease course were analyzed.
RESULTS
Brainstem arteriovenous malformations were symptomatic and bled in 93% and 61% of cases, respectively. Examination was abnormal and initial modified Rankin Scale score was > 3 in 71% and 86% of patients, respectively. The average follow-up time was 6.2 years, and 26% of patients rebled (5.9 %/y). Treatment modalities included conservative, radiosurgical, endovascular, surgical, and multimodality treatment in 13%, 58%, 35%, 16%, and 26% of cases, respectively. The obliteration rate was 60% overall and 39% after radiosurgery, 40% after embolization, and 75% after microsurgery, with respective complication-free cure rates of 71%, 50%, and 0%. Overall procedural mortality and morbidity were 2.3% and 18.6%, respectively. Final modified Rankin Scale score was > 3 in 77% of cases. Neurological deterioration (35%) was related to treatment complications in 74% of cases with a negative impact of surgery (P = .04), palliative embolization (odds ratio = 16), and multimodality treatments (odds ratio = 24). Radiosurgery was inversely associated with worsening (odds ratio = 0.06).
CONCLUSION
Brainstem arteriovenous malformations require individualized treatment decisions. Single-modality treatments with a reasonable chance of complete cure and low complication rate (such as radiosurgery) should be favored.
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Affiliation(s)
- Laurent Thines
- Department of Neurosurgery, Lille University Hospital, Lille, France
| | - Amir R. Dehdashti
- Department of Neurosurgery, Geisinger Neurosciences Institute, Danville, Pennsylvania
| | - Leodante da Costa
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neurosurgery and Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael Tymianski
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karel G. ter Brugge
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert A. Willinsky
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Michael Schwartz
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - MChristopher Wallace
- University of Toronto Brain Vascular Malformation Study Group, Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
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Morihiro Y, Harada K, Kato S, Ishihara H, Shirao S, Nakayama H, Akimura T, Suzuki M. Delayed parenchymal hemorrhage following successful embolization of brainstem arteriovenous malformation. Case report. Neurol Med Chir (Tokyo) 2011; 50:661-4. [PMID: 20805650 DOI: 10.2176/nmc.50.661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 64-year-old man presented with subarachnoid hemorrhage from a small brainstem arteriovenous malformation (AVM). Cerebral angiography showed a small AVM in the lateral midbrain, which was fed by a basilar perforating artery, and drained into the right transverse pontine vein and superior petrous vein. Endovascular embolization in the acute stage was selected to occlude the arteriovenous shunt and provide additional intensive treatment for cerebral spasm with lower risk of rebleeding. The AVM was occluded by embolization using n-butyl cyanoacrylate. Intraparenchymal hemorrhage in the ipsilateral pons was detected 1 month after treatment. The causes of the hemorrhage remain unclear.
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Affiliation(s)
- Yusuke Morihiro
- Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
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14
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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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15
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Gross BA, Batjer HH, Awad IA, Bendok BR. BRAINSTEM CAVERNOUS MALFORMATIONS. Neurosurgery 2009; 64:E805-18; discussion E818. [DOI: 10.1227/01.neu.0000343668.44288.18] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bradley A. Gross
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Issam A. Awad
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Bernard R. Bendok
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
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Ali Z, Prabhakar H, Rath GP, Singh D. Bilateral vocal cord palsy due to brain-stem cavernoma--a diagnostic dilemma! Acta Neurochir (Wien) 2008; 150:845-6. [PMID: 18493702 DOI: 10.1007/s00701-008-1508-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 12/20/2007] [Indexed: 12/01/2022]
Abstract
Vocal cord palsy may result from varied causes. However, cord palsy resulting from a brain-stem cavernoma has never been reported. We report a patient with vocal cord palsy in a 30-year-old male resulting from the brain-stem lesion. The patient became symptomatic each time the lesion bled and improved gradually when the bleeding resolved. Repeated insults on the brain-stem produced permanent cord palsy. Although a rare presentation, brain-stem cavernoma may be considered in the aetiology of cord palsy.
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MESH Headings
- Adult
- Brain Stem Neoplasms/complications
- Brain Stem Neoplasms/diagnosis
- Brain Stem Neoplasms/pathology
- Brain Stem Neoplasms/surgery
- Craniotomy
- Hemangioma, Cavernous, Central Nervous System/complications
- Hemangioma, Cavernous, Central Nervous System/diagnosis
- Hemangioma, Cavernous, Central Nervous System/pathology
- Hemangioma, Cavernous, Central Nervous System/surgery
- Humans
- Magnetic Resonance Imaging
- Male
- Microsurgery
- Neoplasms, Multiple Primary/complications
- Neoplasms, Multiple Primary/diagnosis
- Neoplasms, Multiple Primary/pathology
- Neoplasms, Multiple Primary/surgery
- Postoperative Complications/etiology
- Postoperative Complications/surgery
- Reoperation
- Respiratory Insufficiency/etiology
- Respiratory Insufficiency/surgery
- Vocal Cord Paralysis/etiology
- Vocal Cords/surgery
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Affiliation(s)
- Z Ali
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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17
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Cavernous angiomas of the brain stem and spinal cord. J Clin Neurosci 2008; 5 Suppl:20-5. [PMID: 18639094 DOI: 10.1016/s0967-5868(98)90005-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/1996] [Accepted: 10/30/1996] [Indexed: 11/24/2022]
Abstract
This article reviews the pathology, clinical course and management of cavernous angiomas in the brain stem and spinal cord. Both lesions have been diagnosed with increasing frequency as a result of magnetic resonance image scanning. Brain stem lesions tend to present dramatically; their treatment remains microsurgical excision despite some studies that have looked at the use of radiosurgery. Spinal lesions are either extra-, or more commonly, intramedullary. Intramedullary cavernomas present with a wide spectrum of symptoms ranging from acute haematomyelia to presentations that mimic demylelinating conditions; extramedullary cavernous angiomas tend to produce radicular symptoms or subarachnoid haemorrhage. Both are treated by microsurgical excision.
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Alves de Sousa A. Cavernomes profonds (corps calleux, intraventriculaires, ganglions de la base, insulaires) et du tronc cérébral. Expérience d'une série brésilienne. Neurochirurgie 2007; 53:182-91. [PMID: 17507054 DOI: 10.1016/j.neuchi.2007.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Accepted: 03/20/2007] [Indexed: 11/23/2022]
Abstract
With a review of the literature, we report our experience with surgical treatment of deep-seated cavernomas (intraventricular, of the corpus callosum, the capsula interna, the insula and the brain stem). Outcome was good in all nine patients after surgery for deep-seated brain cavernomas. There we also 13 cases of the brain stem cavernomas treated surgically. Of them, nine patients were stabilized or improved, one patient worsened, one patient died and two were lost to follow-up. Whatever the location, surgery should only concern symptomatic or hemorrhagic lesions close to the pia-matter or the ependyma as well as those covered by a thin layer of parenchyma. Neuronavigation and microsurgical procedures are essential in the treatment of deep-seated cavernomas.
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Kashimura H, Inoue T, Ogasawara K, Ogawa A. Pontine Cavernous Angioma Resected using the Subtemporal, Anterior Transpetrosal Approach Determined Using Three-dimensional Anisotropy Contrast Imaging: Technical Case Report. Oper Neurosurg (Hagerstown) 2006; 58:ONS-E175; discussion ONS-E175. [PMID: 16462620 DOI: 10.1227/01.neu.0000193531.59606.cb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE We describe a case of brainstem cavernous angioma resected by the subtemporal, anterior transpetrosal approach, selected on the basis of three-dimensional anisotropy contrast (3-DAC) imaging. CLINICAL PRESENTATION A 64-year-old woman presented with sudden headache and gait disturbance. Anatomic magnetic resonance imaging showed a mass lesion in the left anterolateral part of the pons. On 3-DAC imaging, posteromedial compression of the left corticospinal and corticopontine tracts by the mass lesion was demonstrated. INTERVENTION The lesion was resected through the anterolateral side of the pons via the subtemporal, anterior transpetrosal approach. Neurological symptoms improved postoperatively, and postoperative 3-DAC imaging demonstrated preservation of the corticospinal and corticopontine tracts. CONCLUSION The technique of 3-DAC imaging may provide important information regarding neural tracts for the planning of brainstem surgery.
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Affiliation(s)
- Hiroshi Kashimura
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
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20
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Quiñones-Hinojosa A, Lyon R, Du R, Lawton MT. Intraoperative Motor Mapping of the Cerebral Peduncle during Resection of a Midbrain Cavernous Malformation: Technical Case Report. Oper Neurosurg (Hagerstown) 2005; 56:E439; discussion E439. [PMID: 15794843 DOI: 10.1227/01.neu.0000156784.46143.a5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Accepted: 01/07/2005] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE:
Brainstem cavernous malformations that seem to come to a pial or ependymal surface on preoperative magnetic resonance imaging studies may, in fact, be covered by an intact layer of neural tissue. For cavernous malformations in the cerebral peduncle, intraoperative stimulation mapping with a miniaturized probe can determine whether this overlying tissue harbors fibers in the corticospinal tract. In addition, intermittent monitoring with transcranial motor evoked potentials (TcMEPs) helps to protect this vital pathway during resection of the lesion.
CLINICAL PRESENTATION:
A 20-year-old woman collapsed after a cavernous malformation in the left cerebral peduncle hemorrhaged into the pons, midbrain, and thalamus. She presented with right hemiparesis and left oculomotor palsy.
INTERVENTION:
The cavernous malformation was completely resected through a left orbitozygomatic craniotomy and transsylvian approach. Stimulation mapping of the cerebral peduncle with a Kartush probe (Medtronic Xomed, Inc., Jacksonville, FL) identified the corticospinal tract lateral to the lesion, and a layer of tissue over the lesion harbored no motor fibers. TcMEP monitoring helped to guide the resection, with increased voltage thresholds and altered waveform morphologies indicating transient impaired motor conduction. All TcMEP changes returned to baseline by the end of the procedure, and the patient's hemiparesis improved after surgery.
CONCLUSION:
Stimulation mapping of the corticospinal tract and intermittent TcMEPs is a safe and simple surgical adjunct. Expanded monitoring of the motor pathway during the resection of cerebral peduncle cavernous malformations may improve the safety of these operations.
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MESH Headings
- Adult
- Brain Mapping
- Cerebral Hemorrhage/diagnosis
- Cerebral Hemorrhage/etiology
- Electric Stimulation/instrumentation
- Equipment Design
- Evoked Potentials, Motor
- Female
- Hemangioma, Cavernous, Central Nervous System/complications
- Hemangioma, Cavernous, Central Nervous System/diagnosis
- Hemangioma, Cavernous, Central Nervous System/physiopathology
- Hemangioma, Cavernous, Central Nervous System/surgery
- Hematoma/diagnosis
- Hematoma/etiology
- Hemiplegia/etiology
- Humans
- Magnetic Resonance Imaging
- Mesencephalon/surgery
- Monitoring, Intraoperative
- Ophthalmoplegia/etiology
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Affiliation(s)
- Alfredo Quiñones-Hinojosa
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA.
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Liscák R, Vladyka V, Simonová G, Vymazal J, Novotny J. Gamma knife surgery of brain cavernous hemangiomas. J Neurosurg 2005; 102 Suppl:207-13. [PMID: 15662812 DOI: 10.3171/jns.2005.102.s_supplement.0207] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object.The authors conducted a study to record more detailed information about the natural course and factors predictive of outcome following gamma knife surgery (GKS) for cavernous hemangiomas.Methods.One hundred twelve patients with brain cavernous hemangiomas underwent GKS between 1993 and 2000. The median prescription dose was 16 Gy. One hundred seven patients were followed for a median of 48 months (range 6–114 months). The rebleeding rate was 1.6%, which is not significantly different with that prior to radiosurgery (2%). An increase in volume was observed in 1.8% of cases and a decrease in 45%. Perilesional edema was detected in 27% of patients, which, together with the rebleeding, caused a transient morbidity rate of 20.5% and permanent morbidity rate of 4.5%. Before radiosurgery 39% of patients suffered from epilepsy and this improved in 45% of them. Two patients with brainstem cavernous hemangiomas died due to rebleeding. Rebleeding was more frequent in female middle-aged patients with a history of bleeding, a larger lesion volume, and a prescription dose below 13 Gy. Edema after GKS occurred more frequently in patients who had surgery, a larger lesion volume, and in those in whom the prescription dose was more than 13 Gy.Conclusions.Gamma knife surgery of cavernous hemangiomas can produce an acceptable rate of morbidity, which can be reduced by using a lower margin dose. Lesion regression was observed in many patients. Radiosurgery seems to remain a suitable treatment modality in carefully selected patients.
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Affiliation(s)
- Roman Liscák
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
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22
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Abstract
Object. The authors conducted a study to record more detailed information about the natural course and factors predictive of outcome following gamma knife surgery (GKS) for cavernous hemangiomas.
Methods. One hundred twelve patients with brain cavernous hemangiomas underwent GKS between 1993 and 2000. The median prescription dose was 16 Gy. One hundred seven patients were followed for a median of 48 months (range 6–114 months). The rebleeding rate was 1.6%, which is not significantly different with that prior to radiosurgery (2%). An increase in volume was observed in 1.8% of cases and a decrease in 45%. Perilesional edema was detected in 27% of patients, which, together with the rebleeding, caused a transient morbidity rate of 20.5% and permanent morbidity rate of 4.5%. Before radiosurgery 39% of patients suffered from epilepsy and this improved in 45% of them. Two patients with brainstem cavernous hemangiomas died due to rebleeding. Rebleeding was more frequent in female middle-aged patients with a history of bleeding, a larger lesion volume, and a prescription dose below 13 Gy. Edema after GKS occurred more frequently in patients who had surgery, a larger lesion volume, and in those in whom the prescription dose was more than 13 Gy.
Conclusions. Gamma knife surgery of cavernous hemangiomas can produce an acceptable rate of morbidity, which can be reduced by using a lower margin dose. Lesion regression was observed in many patients. Radiosurgery seems to remain a suitable treatment modality in carefully selected patients.
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Rodríguez R, Molet J, de Teresa S, Treserras P, Clavel P, Cano P, Solivera J, Muñoz F, Bartumeus F. Monitorización neurofisiológica intraoperatoria del tronco del encéfalo en un caso de cavernoma en protuberancia. Neurocirugia (Astur) 2005. [DOI: 10.1016/s1130-1473(05)70416-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kikuta KI, Nozaki K, Takahashi JA, Miyamoto S, Kikuchi H, Hashimoto N. Postoperative evaluation of microsurgical resection for cavernous malformations of the brainstem. J Neurosurg 2004; 101:607-12. [PMID: 15481714 DOI: 10.3171/jns.2004.101.4.0607] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The aim of this study was to propose criteria to determine whether complete resection of cavernous malformations in the brainstem had been achieved.
Methods. The authors retrospectively analyzed data in 10 patients harboring a single cavernous malformation who had presented with hemorrhagic symptoms and had been followed up for longer than 2 years postsurgery. The study population consisted of five male and five female patients ranging in age from 13 to 57 years (mean 36.8 years). When preoperative magnetic resonance (MR) images demonstrated the lesion as a homogeneous hyperintense mass, the surgery was defined as complete or incomplete based on intraoperative findings. When preoperative MR images revealed other findings, complete resection was determined according to whether postoperative MR imaging results demonstrated lesions distinct from the peripheral hemosiderin rim. Among the 13 operations in this series, nine resulted in complete resection and were associated with no postoperative clinical relapse of hemorrhage, whereas four operations resulted in incomplete resection and were correlated with postoperative recurrent hemorrhage. The seven patients in whom the outcome of the initial operation was complete demonstrated good neurological recovery in the long-term follow-up period, whereas the three patients in whom the outcome of the initial surgery was judged to be incomplete showed inadequate neurological recovery due to recurrent hemorrhage.
Conclusions. The criteria proposed in this study to evaluate surgical treatment may be a reliable means of predicting the recurrence of hemorrhage postoperatively.
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Affiliation(s)
- Ken-ichiro Kikuta
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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25
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Tamano Y, Ujiie H, Kawamata T, Hori T. Continuous Laryngoscopic Vocal Cord Monitoring for Vascular Malformation Surgery in the Medulla Oblongata: Technical Note. Neurosurgery 2004; 54:232-5; discussion 235. [PMID: 14683564 DOI: 10.1227/01.neu.0000097519.38937.fd] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2002] [Accepted: 09/04/2003] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
Resection of lesions located in the medulla oblongata may result in significant morbidity. The most lethal complications are swallowing disturbances, which can lead to aspiration pneumonia. To prevent this problem, the lower cranial nerves can be mapped with recording needles placed in the posterior pharyngeal wall and the tongue. However, mapping alone is not sufficient to preserve the lower cranial nerves and swallowing functions. To overcome this problem, we attempted to devise a method to intraoperatively monitor vocal cord movements with a laryngoscope. We used this method, in addition to other types of brainstem mapping, in three cases.
METHODS
Recording needles were inserted into the posterior pharyngeal wall and the tongue, to record the responses of Cranial Nerves IX and XII. A laryngoscope was inserted orally, for direct observation of vocal cord movements, and was maintained until the end of the operation. The floor of the fourth ventricle was stimulated with a monopolar stimulator. Somatosensory evoked potentials, auditory evoked potentials, and motor evoked potentials were simultaneously monitored.
RESULTS
We were able to confirm synchronized vocal cord adduction with stimulation of the expected vagal trigonum location and to monitor rhythmic vocal cord movements during spontaneous respiration. In all three cases, we removed the lesions without postoperative complications.
CONCLUSION
In addition to intraoperative vocal cord monitoring with a laryngoscope, we could safely determine the optimal location for the first incision in the floor of the fourth ventricle. Potentially lethal postoperative complications can be avoided with brainstem mapping and vocal cord monitoring.
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Affiliation(s)
- Yoshinori Tamano
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan
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26
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Vascular Malformations of the Posterior Fossa: Clinical Features, Treatment, and Outcomes. ACTA ACUST UNITED AC 2003. [DOI: 10.1097/00013414-200312000-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Sakakibara R, Uchiyama T, Yoshiyama M, Aotsuka A, Mori M, Kanesaka T, Hattori T, Yamanishi T. Micturitional disturbance in a patient with a spinal cavernous angioma. Neurourol Urodyn 2003; 22:606-10. [PMID: 12951673 DOI: 10.1002/nau.10039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A 58-year-old woman had a 3-year history of numbness in the right leg, which developed into thoracic transverse myelopathy and urinary retention. After referral to our department, MRI scans revealed a lesion with a target appearance at the T10-11 spinal cord with multiple silent cerebral lesions, which confirmed the diagnosis of cavernous angioma. Gamma-knife surgery was not indicated, considering the risk of adverse effects. The patient gradually became able to urinate, but had urge urinary incontinence. The first urodynamic studies (conducted 3 months after full clinical manifestations of transverse myelopathy) showed detrusor hyperreflexia (DH), decreased bladder sensation during bladder filling, detrusor-sphincter dyssynergia (DSD), and weak detrusor on voiding. However, urinary retention appeared again without change of neurologic signs. The second urodynamic studies (conducted 2 months later) showed less marked DH during bladder filling, and equivocal DSD but marked weak detrusor on voiding. The patient started taking oral prazosin hydrochloride (6 mg/day), which gradually ameliorated her voiding difficulty. Lesions in the lateral and dorsal columns of the spinal cord seem to be responsible for the micturitional disturbance in our patient with spinal cavernous angioma.
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Kashimura H, Inoue T, Ogasawara K, Ogawa A. Preoperative Evaluation of Neural Tracts by Use of Three-dimensional Anisotropy Contrast Imaging in a Patient with Brainstem Cavernous Angioma: Technical Case Report. Neurosurgery 2003. [DOI: 10.1093/neurosurgery/52.5.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVE AND IMPORTANCE
We describe a case of brainstem cavernous angioma in which the neural tracts were evaluated before surgery by three-dimensional anisotropy contrast (3-DAC) magnetic resonance imaging.
CLINICAL PRESENTATION
A 64-year-old man presented with a cavernous angioma located intrinsically in the brainstem and manifesting as gait ataxia. 3-DAC imaging demonstrated that the lesion was located outside the left inferior cerebellar peduncle and inside the middle cerebellar peduncle.
INTERVENTION
The intact brain surface was incised, and the lesion was removed successfully on the basis of the preoperative 3-DAC images. The patient exhibited temporary exacerbation of his gait ataxia, but the symptom improved 3 months after surgery. Postoperative 3-DAC imaging demonstrated resection of the lesion and preservation of the left inferior and middle cerebellar peduncles.
CONCLUSION
3-DAC imaging may provide essential information about the neural tracts for the planning of brainstem surgery.
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Affiliation(s)
- Hiroshi Kashimura
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takashi Inoue
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Akira Ogawa
- Department of Neurosurgery, Iwate Medical University School of Medicine, Morioka, Japan
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Kashimura H, Inoue T, Ogasawara K, Ogawa A. Preoperative Evaluation of Neural Tracts by Use of Three-dimensional Anisotropy Contrast Imaging in a Patient with Brainstem Cavernous Angioma: Technical Case Report. Neurosurgery 2003. [DOI: 10.1227/01.neu.0000058025.94734.a3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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30
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Porter R, Zabramski JM, Lanzino G, Feiz-Erfan I, Spetzler RF. Surgical treatment of brain stem cavernous malformations. ACTA ACUST UNITED AC 2002. [DOI: 10.1053/otns.2002.32491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hasegawa T, McInerney J, Kondziolka D, Lee JY, Flickinger JC, Lunsford LD. Long-term Results after Stereotactic Radiosurgery for Patients with Cavernous Malformations. Neurosurgery 2002. [DOI: 10.1227/00006123-200206000-00003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hasegawa T, McInerney J, Kondziolka D, Lee JYK, Flickinger JC, Lunsford LD. Long-term results after stereotactic radiosurgery for patients with cavernous malformations. Neurosurgery 2002; 50:1190-7; discussion 1197-8. [PMID: 12015835 DOI: 10.1097/00006123-200206000-00003] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2001] [Accepted: 01/14/2002] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Stereotactic radiosurgery has been used for patients with high-risk cavernous malformations of the brain. We performed radiosurgery for patients with symptomatic, imaging-confirmed hemorrhages for which resection was believed to be associated with high risk. This study examines the long-term hemorrhage rate after radiosurgery. METHODS We reviewed data obtained before and after gamma knife radiosurgery on 82 patients treated between 1987 and 2000. Most patients had multiple hemorrhages from brainstem or diencephalic cavernous malformations. Follow-up data were examined to identify hemorrhages, and an overall hemorrhage rate was calculated. RESULTS Observation before treatment averaged 4.33 years (range, 0.17-18 yr) for a total of 354 patient-years. During this period, 202 hemorrhages were observed, for an annual hemorrhage rate of 33.9%, excluding the first hemorrhage. Temporal clustering of hemorrhages was not significant. After radiosurgery, patient follow-up averaged 5 years (range, 0.42-12.08 yr), for a total of 401 patient-years. During this period, 19 hemorrhages were identified, 17 in the first 2 years posttreatment and 2 after 2 years. The annual hemorrhage rate was 12.3% per year for the first 2 years after radiosurgery, followed by 0.76% per year from Years 2 to 12. Eleven patients had new neurological symptoms without hemorrhage after radiosurgery (13.4%). The symptoms were minor in six of these patients and temporary in five. CONCLUSION Radiosurgery confers a reduction in the risk of hemorrhage for high-risk cavernous malformations. Risk reduction, although in evidence during initial follow-up, is most pronounced after 2 years. Given the difficulty of identifying high-risk patients, treatment after one major hemorrhage should be considered in selected younger patients. Such a strategy warrants further investigation.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurological Surgery and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Sandalcioglu IE, Wiedemayer H, Secer S, Asgari S, Stolke D. Surgical removal of brain stem cavernous malformations: surgical indications, technical considerations, and results. J Neurol Neurosurg Psychiatry 2002; 72:351-5. [PMID: 11861694 PMCID: PMC1737795 DOI: 10.1136/jnnp.72.3.351] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study was undertaken to review the indications for surgical treatment of brain stem cavernomas and to develop strategies to minimise the complications of surgery. PATIENTS AND RESULTS Twelve patients underwent surgical resection of a brain stem cavernoma due to symptoms caused by one or more haemorrhages. Age ranged from 18 to 47 years (mean 29.2 years). Long term follow up (mean 3.7 years) included a complete neurological examination and annual MRI studies. The annual haemorrhage rate was 6.8 %/patient/year and a rate of 1.9 rehaemorrhages/patient/year was found. Surgery was performed under microsurgical conditions with endoscopic assistance, use of neuronavigation, and neurophysiological monitoring. Navigation proved to be reliable when applied in an early stage of operative procedure with minimal brain retraction. Endoscopy was a useful tool in some cases to confirm complete resection of the lesion and to ascertain haemostasis. Ten patients had a new neurological deficit in the early postoperative period, nine of these were transient. At the last follow up the neurological state was improved in five patients, unchanged in six, and worse in one compared with the preoperative conditions. The preoperative average Rankin score was 2.2 points and had improved at the last follow up by 0.6 points to 1.6 points. CONCLUSIONS Symptomatic brain stem cavernomas should be considered for surgical treatment after the first bleeding. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory. The additional use of modern tools such as neuronavigation, endoscopic assistance, and monitoring can contribute to the safety of the procedure.
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Affiliation(s)
- I E Sandalcioglu
- Department of Neurosurgery, University of Essen Medical School, Essen, Germany.
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Reisch R, Bettag M, Perneczky A. Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem. SURGICAL NEUROLOGY 2001; 56:106-15; discussion 115-6. [PMID: 11580947 DOI: 10.1016/s0090-3019(01)00529-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The natural history of brain stem cavernous malformations is unfavorable because of their high hemorrhage rate and resulting neurological deterioration among patients. However, direct surgery of intrinsic and anteriorly situated cavernomas is hazardous and leads to a bad postoperative outcome because of trauma to lateral and dorsally situated eloquent areas of the brain stem. METHODS We review the cases of two patients with symptomatic cavernous malformations of the anterior brain stem and describe the usefulness of a transoral-transclival approach. A 23-year-old man developed progressive hemihypaesthesia and paraesthesia, hemiparesis with gait ataxia, dysarthria, dysphonia, and dysphagia. A 38-year-old woman suffered from an acute onset of vertigo with nausea and vomiting, diplopia, and paraesthesia of the left hand and foot. In both patients, computed tomography demonstrated the presence of brain stem hemorrhage, because of cavernous malformation. Magnetic resonance imaging showed a close proximity of the lesions to the pia mater only on the ventral surface of the brain stem. RESULTS In both patients, the cavernomas could be safely approached and completely resected via a transoral transclival route. Three months after surgery, neurological examination revealed marked neurological improvement. The 23-year-old patient showed slight gait ataxia, no hemiparesis, no cranial nerve palsies; the 38-year-old woman demonstrated no neurological symptoms except for minimal motor dysfunction of the left hand. In both cases, under perioperative prophylactic antibiotics, no meningitis was observed. The patients could subsequently return to their previous employment. CONCLUSION The transoral transclival approach for ventrally situated brain stem cavernomas allows a largely atraumatic resection of the lesion.
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Affiliation(s)
- R Reisch
- Department of Neurosurgery, Johannes Gutenberg University, Mainz, Germany
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Folkersma H, Mooij JJ. Follow-up of 13 patients with surgical treatment of cerebral cavernous malformations: effect on epilepsy and patient disability. Clin Neurol Neurosurg 2001; 103:67-71. [PMID: 11516547 DOI: 10.1016/s0303-8467(01)00113-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We report a series of 13 patients with surgical treatment of cerebral cavernous malformation (CM). The aim of this study was to investigate postoperative patient disability and seizure control in patients with CM in order to clarify indications for neurosurgical removal. In our series we emphasize the beneficial effect of excision of CMs. We also give an overview of the current literature covering options for treatment in surgically inaccessible CMs. METHODS In this retrospective study we describe the clinical outcomes of neurosurgical intervention in 13 patients with a CM. Seven patients had epilepsy at presentation and six had focal neurological deficits due to intracerebral haemorrhage (five patients) or mass effect due to the CM (one patient). The modified Rankin scale was used to define patient disability pre- and postoperatively. An overview of the indications for surgery and postoperative outcome with follow up periods of 1-6 years (mean: 3.3 years) are provided. RESULTS In all patients presenting with epilepsy a reduction in seizure frequency was seen. Four of them became seizure-free postoperatively. The six patients with neurological deficits due to intracerebral haemorrhage or mass effect due to the CM showed clinical improvement postoperatively, two of them made full recoveries. Improvement of the postoperative Rankin score was seen in six of 13 patients. CONCLUSION Improvement in seizure control and reduction in patient disability warrants surgical intervention in symptomatic CMs.
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Affiliation(s)
- H Folkersma
- Department of Neurosurgery, University Hospital AZG, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
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Beltramello A, Lombardo MC, Masotto B, Bricolog A. Imaging of brain stem tumors. ACTA ACUST UNITED AC 2000. [DOI: 10.1053/oy.2000.6571] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Musumeci A, Cristofori L, Bricolo A. Persistent hiccup as presenting symptom in medulla oblongata cavernoma: a case report and review of the literature. Clin Neurol Neurosurg 2000; 102:13-7. [PMID: 10717396 DOI: 10.1016/s0303-8467(99)00058-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A rare case of persistent intractable hiccup as presenting symptom of cavernous angioma in the medulla oblongata is reported. Pathophysiologic hypotheses about the triggering mechanism of hiccup are discussed, with special reference to the causes affecting the central nervous system. A review of the literature concerning medullary lesions presenting with persistent hiccup is also reported. Finally we have included some brief considerations about cavernous angiomas and the patterns of their clinical presentation, focusing on those located in the medulla oblongata.
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Affiliation(s)
- A Musumeci
- Department of Neurosurgery, University Hospital, Piazzale Stefani 1, 37126, Verona, Italy.
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Abstract
BACKGROUND Only few anecdotal reports and small series of thalamic cavernous malformations have been reported. It follows that the clinical behavior and management are poorly understood; in particular, experiences with the surgical treatment of these lesions are scarce. METHODS The clinical course, treatment, and outcome of 12 patients (10 females and 2 males, mean age 36 years) with symptomatic cavernous malformations of the thalamus are reviewed. Eight patients (66%) presented with cerebral hemorrhage, one with progressive neurological deficit and three with hydrocephalus/increased intracranial pressure; associated venous anomalies were found in three cases. Treatment consisted of radical surgery in four cases with progressive neurological decline or recurrent disabling hemorrhage, radiosurgery (one case), evacuation of a chronic satellite hematoma (one case), ventriculoperitoneal shunt for hydrocephalus (one case) and observation (five cases). Operative treatment in four cases included transcallosal, trigonal, and occipital interhemispheric approaches. RESULTS In the surgical group, one patient died, two improved after operation, and one remained the same. Of the patients not operated on radically, one had recurrent hemorrhage 4 months after radiosurgery, one remains stable 8 years after ventriculoperitoneal shunt, and one 3 years after aspiration of a satellite hematoma. Five other patients presenting with thalamic hemorrhage were treated conservatively; recurrent hemorrhage occurred in two cases at 1 month and at 2 years, leaving a mild residual deficit in both cases. Overall, rehemorrhage occurred in four cases (50%) at a mean interval of 18 months after the first bleeding; the annual hemorrhage rate was 6.1%. CONCLUSIONS Thalamic malformations are more likely to be symptomatic from small hemorrhages compared with lesions in the cerebral hemispheres; progressive growth may also occur with third ventricle invasion or caudal extension to the midbrain. Their high-risk location deters heavy-handed management, but they should not be left long untreated. Both surgery and radiosurgery have been used in the management of thalamic cavernomas reported in the literature. Definite surgical indications include progressive neurological decline and recurrent hemorrhages of malformations abutting the ventricular surface or the posterior incisural space; the complex anatomy of the deep venous system and the association with unexpected venous anomalies complicates the removal of these lesions.
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Affiliation(s)
- E Pozzati
- Division of Neurosurgery, Bellaria Hospital, Bologna, Italy
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Abstract
The purpose of this study was to evaluate the feasibility and usefulness of cranial nerve nuclei monitoring during resection of brainstem cavernous malformations. Eleven patients with brainstem cavernous malformations underwent resection of their malformations utilizing cranial nerve nuclei monitoring. Cranial nerves V and VII were monitored by placing electrodes in muscle groups innervated by these nerves and recording manipulation-induced neurotonic discharges and triggered electromyographic (EMG) activity, after electrical stimulation of the corresponding brainstem nuclei. Seven of 11 procedures (64%) with cranial nerve nuclei monitoring were noted to have cranial nerve nuclei activity corresponding to manipulation of the nuclei. The cavernous malformation was completely resected in 5 of 7 cases with cranial nerve nuclei activity and in all 4 cases without activity. In the remaining 2 cases, the cavernous malformation was not resected due to the proximity of the monitored cranial nerve nuclei to the cavernous malformation and to increasing neurotonic activity as the cavernous malformation was approached. None of the 11 patients had new permanent postoperative deficits corresponding to the cranial nerve nuclei monitored; 1 patient had a transient partial facial palsy lasting 2 days. Preliminary results indicate that cranial nerve nuclei monitoring proves useful in preserving neurologic function and reducing surgical morbidity during resection of brainstem cavernous malformations, particularly indicating when lesion resection places these nuclei at risk.
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Affiliation(s)
- S D Chang
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California 94305, USA
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Cantore G, Missori P, Santoro A. Cavernous angiomas of the brain stem. Intra-axial anatomical pitfalls and surgical strategies. SURGICAL NEUROLOGY 1999; 52:84-93; discussion 93-4. [PMID: 10390181 DOI: 10.1016/s0090-3019(99)00036-1] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND We review the surgical anatomy of the brain stem in relation to the surgical approaches adopted for treatment of cavernomas and identify possible "safe entry zones" on the anterior face of the brainstem. METHODS Twelve symptomatic patients with cavernoma or telangectasia of the brain stem were surgically treated. The brain stem was divided into the following anatomical areas: ventral medulla, dorsal medulla, dorsal pons, ventral pons, ventral mesencephalon, and dorsal mesencephalon, so that the surgical approach could be "individualized" according to the position of the cavernoma, the nerve fasciculi and nuclei. RESULTS On the anterior surface of the brain stem a medullar paramedian oblique access to the anterolateral sulcus and a paramedian sagittal pons access seem to avoid the main nerve fasciculi and nuclei. CONCLUSIONS Although the parenchymal window produced by the cavernoma is the most important parameter for the choice of approach, fairly safe entry zones may be identified even on the anterior surface of the medulla and pons.
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Affiliation(s)
- G Cantore
- Department of Neurosciences, Neurosurgery I, University of Rome La Sapienza, Italy
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Schaller C, Schramm J, Haun D. Significance of factors contributing to surgical complications and to late outcome after elective surgery of cerebral arteriovenous malformations. J Neurol Neurosurg Psychiatry 1998; 65:547-54. [PMID: 9771782 PMCID: PMC2170302 DOI: 10.1136/jnnp.65.4.547] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study focuses on the relevance of size, eloquence, type of venous drainage, the Spetzler-Martin scale as a whole, and other factors, such as rupture of cerebral arteriovenous malformations (AVMs) for the prediction of neurological deficits in the context of microsurgical AVM removal. METHODS One hundred and fifty patients with AVMs, whose data were retrieved from a prospectively employed computerised data bank were included. Seventeen patients (11.3%) underwent preoperative embolisation. According to the Spetzler-Martin scale they were graded as follows: 22.0% grade I, 32.0% grade II, 29.3% grade III, 14.0% grade IV, and 2.7% grade V. Intracerebral haemorrhage was present in 39.0%. The AVMs were <3 cm in 52.00/0, 3-6 cm in 43.3% and >6 cm in 4.7%; 59.3% of the AVMs were eloquently located and 29.3% had deep venous drainage (DVD). Follow up information was assessed 6 months after surgery in all but one patient, who died. The applied statistical test was chi2. RESULTS Surgical morbidity was 15.3%. Early new deficits were noted in 39.3%, permanent new deficits in 10.6%, being significant (major) in 7.3%. The occurrence of permanent deficits correlated significantly with size, deep venous drainage, and the Spetzler-Martin scale. There was statistical evidence for a trend in risk of poor surgical outcome across the three categories non-eloquent, "less eloquent" (for example, visual cortex) and "highly eloquent" (brainstem, basal ganglia, or precentral cortex) with the last being associated with the highest risk for permanent neurological compromise. CONCLUSION "Eloquence" of the Spetzler-Martin scale should be divided into "highly eloquent" and "less eloquent", which is important for risk analysis of the treatment of asymptomatic and deep seated AVMs and for future trials comparing various treatment modalities. In addition, resection of eloquent AVMs v non-eloquent ones is significantly associated with higher surgical morbidity.
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Affiliation(s)
- C Schaller
- Department of Neurosurgery, University of Bonn, Germany.
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Slater PW, Welling DB, Goodman JH, Miner ME. Middle fossa transpetrosal approach for petroclival and brainstem tumors. Laryngoscope 1998; 108:1408-12. [PMID: 9738768 DOI: 10.1097/00005537-199809000-00030] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of the study was to demonstrate the utility of the middle fossa transpetrosal approach with anterior petrosectomy for difficult-to-access petroclival and pontine lesions. STUDY DESIGN Retrospective case review in academic tertiary referral center. METHODS Patients for inclusion had pontine and prepontine lesions of the petroclival region. Middle fossa transpetrosal approach with anterior petrosectomy with excision or biopsy of the lesion was performed. The main outcome measure was postoperative neurologic status including motor and cranial nerve function. RESULTS No patient experienced neuromuscular compromise or cranial nerve deficits as a direct result of the surgical procedure. Complications consisted of a subdural temporal lobe hemorrhage and one case of cerebrospinal fluid rhinorrhea. CONCLUSIONS The middle fossa transpetrosal approach with anterior petrosectomy was utilized for five patients with petroclival or pontine tumors. In this small series, it served well to spare cranial nerves and allowed avoidance of serious vascular injury. To our knowledge, this is the first reported use of this procedure for pontine venous angiomas.
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Affiliation(s)
- P W Slater
- Department of Otolaryngology, The Ohio State University, Columbus 43210, USA
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Chang SD, Levy RP, Adler JR, Martin DP, Krakovitz PR, Steinberg GK. Stereotactic radiosurgery of angiographically occult vascular malformations: 14-year experience. Neurosurgery 1998; 43:213-20; discussion 220-1. [PMID: 9696072 DOI: 10.1097/00006123-199808000-00011] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Radiosurgery is generally effective in obliterating true arteriovenous malformations, but less is known about its effects on angiographically occult vascular malformations (AOVMs). Since July 1983, 57 patients with surgically inaccessible AOVMs of the brain were treated using helium ion (47 patients) or linear accelerator (10 patients) radiosurgery. This study retrospectively evaluates the response of these AOVMs to treatment. METHODS All patients presented with previous hemorrhage. The mean patient age was 35.6 years (range, 13-71 yr). The mean AOVM volume was 2.25 cm3 (range, 0.080-15.2 cm3), treated with a mean of 18.0 Gy equivalent (physical dose x relative biological effectiveness, which is 1.3 for helium ion Bragg peak) (range, 7.0-40 Gy equivalent). The Drake scale scores before treatment were as follows: excellent (25 patients), good (26 patients), and poor (6 patients). The mean follow-up period was 7.5 years (range, 9 mo-13.8 yr). RESULTS Eighteen patients (32%) bled symptomatically (20 hemorrhages) after radiosurgery. Sixteen hemorrhages occurred within 36 months after radiosurgery (9.4% annual bleed rate; 16 hemorrhages/171 patient yr); 4 hemorrhages occurred more than 36 months after treatment (1.6% annual bleed rate; 4 hemorrhages/257 patient yr) (P < 0.001). Complications included symptomatic radiation edema (four patients, 7%), necrosis (one patient, 2%), and increased seizure frequency (one patient, 2%). Eight patients underwent surgical resection of their AOVMs 8 to 59 months after radiosurgery because of subsequent hemorrhage. The Drake scale scores after treatment were as follows: excellent (25 patients), good (24 patients), poor (3 patients), and dead (5 patients, 3 of whom died as a result of causes unrelated to the AOVMs or radiosurgery). CONCLUSION Radiosurgery may be useful for AOVMs located in surgically inaccessible regions of the brain. A significant decrease in bleed rate exists more than 3 years after treatment compared with the bleed rate within 3 years of treatment. Because current neuroradiological techniques are not able to image obliterative response in these slow-flow vascular lesions, longer term clinical follow-up is required.
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Affiliation(s)
- S D Chang
- Department of Neurosurgery, Stanford Stroke Center, Stanford University School of Medicine, California, USA
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Bogucki J, Gielecki J, Czernicki Z. The anatomical aspects of a surgical approach through the floor of the fourth ventricle. Acta Neurochir (Wien) 1998; 139:1014-9. [PMID: 9442213 DOI: 10.1007/bf01411553] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In 1993 Kyoshima et al. introduced safe entry zones in the region of the 4th ventricle floor: infrafacial triangle and suprafacial triangle. Is it possible to demarcate these zones precisely in every case intra-operatively? A postmortem study of 40 brainstems of patients who had died of non-brain disease was performed to evaluate the degree of individual morphological and morphometrical variability of the 4th ventricle floor. The purpose of this study was to find constant landmarks and distances within the rhomboid fossa region which would help a neurosurgeon to determine safe approach zones through the 4th ventricle floor to brainstem lesions. Several anatomical landmarks-median sulcus, obex, vestibular area, vagal triangle, hypoglossal triangle-were found to be sufficiently visible in all examined brainstems. However, the facial colliculus which is a border structure between the infrafacial and suprafacial safe approach zone was poorly visible in about 37% of the analyzed material. The striae medullares were not found to be good orientation structures as they were not visible in 30% of the material and exhibited individual variability of a high degree in relation to their number and arrangement. In the morphometrical study analyzed measurements were taken by utilizing the digital image analyzer MULTISCAN. Based on the results obtained the authors suggest new borders of the infrafacial safe approach zone and morphometrical directions to determine the suprafacial safe approach zone in cases when the facial colliculus is not clearly visible or invisible intra-operatively.
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Affiliation(s)
- J Bogucki
- Department of Neurosurgery, Polish Academy of Sciences, Warsaw, Poland
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Duffau H, Capelle L, Sichez JP, Faillot T, Bitar A, Arthuis F, Van Effenterre R, Fohanno D. Early radiologically proven rebleeding from intracranial cavernous angiomas: report of 6 cases and review of the literature. Acta Neurochir (Wien) 1997; 139:914-22. [PMID: 9401650 DOI: 10.1007/bf01411299] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although intracranial cavernomas are known to cause haemorrhage, data concerning the frequency, severity and delay of recurrent bleedings are controversial. We report a series of 6 patients with histologically proven cavernoma, presenting with early clinical signs and radiological proof of rebleeding, that is occurring in the first month after initial overt haemorrhage. These 6 cases have been selected from a series of 142 patients seen between 1980 and 1995 in our department with cavernous angiomas or so-called AOVMs, of whom 93 presented with clinical symptoms of haemorrhage (34 patients presented symptoms of one or more rebleeding, but only 6 had radiological proof). All patients suffered neurological worsening due to the rebleeding, with an increase of the size of the haematoma on the CT scan. Five MRIs were performed at the acute stage: 3 showed evidence of cavernoma (60%). All patients underwent surgery at the acute stage of the rebleeding, with 5 improvements and 1 stabilization. A cavernous angioma was found in 5 cases at first surgery, but a further operation was necessary in the last patient to find and remove the cavernoma, after a second rebleeding following the first intervention. Our series reveals a high frequency of rebleeding after a first intracranial haemorrhage from a cavernous angioma, and highlights the precocity of such rebleedings. Therefore, we advocate early aggressive surgical management: in cases of cavernoma revealed by a first clinical overt haemorrhage, when there is strong radiological suspicion at the acute stage; and in all cases of rebleeding, even without radiological evidence of malformation, in the absence of vascular risk factors. Surgical indication must be discussed in particular cases of cavernomas of the brain stem when neither the haematoma nor the cavernoma reach the surface, and in deep supratentorial cavernomas, when the neurological status is good, because of the therapeutic risk.
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Affiliation(s)
- H Duffau
- Department of Neurosurgery 1, Hôpital de la Salpêtrière, Paris, France
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Suzuki K, Matsumoto M, Ohta M, Sasaki T, Kodama N. Experimental study for identification of the facial colliculus using electromyography and antidromic evoked potentials. Neurosurgery 1997; 41:1130-5; discussion 1135-6. [PMID: 9361068 DOI: 10.1097/00006123-199711000-00021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The facial colliculus is a reliable landmark for a surgical approach via the fourth ventricle. Our aim is to elucidate the most suitable electrophysiological methods for identification of the facial colliculus. We evaluated the usefulness of facial electromyography and antidromic evoked potentials of the facial nerve. The effect of stimulation on cardiorespiratory function is also studied. METHODS We localized the facial colliculus by facial electromyography and antidromic facial evoked potentials in adult dogs. To determine the most effective stimulus pattern, intensity was varied, and both monopolar and bipolar electrical stimulation were tried. To confirm the cardiorespiratory effect of the stimulation, systemic blood pressure, heart rate, respiratory rate, and thoracic excursion were measured. After administration of atropine sulfate, changes in vital signs were recorded. RESULTS A stable facial electromyographic wave form was produced by 0.1-mA monopolar stimulation of a small portion of the fourth ventricular floor (4 mm2). Using 0.1-mA bipolar stimulation, the same wave form was obtained. As saline was gradually added around the electrodes, the amplitude of the response gradually decreased; however, the response with monopolar stimulation was more stable than that with bipolar stimulation. Stimulation of the facial colliculus with greater than 2 mA caused transient hypotension and bradycardia; respiratory arrest occurred with 3 mA stimulation. Administration of atropine sulfate (0.01 mg/kg) decreased these responses. Antidromic facial evoked potentials were recorded only at "hot points" that existed within 2 mm of the facial colliculus. CONCLUSION Our study resulted in three findings. First, the most suitable electrophysiological stimulation of the fourth ventricular floor for identification of the facial colliculus was 0.1-mA monopolar stimulation. Second, significant alteration in cardiorespiratory function appeared with greater than 1-mA stimulation. Third, a recording of an antidromic facial evoked potential can identify the facial colliculus more safely than direct stimulation of the facial colliculus. Both orthodromic and antidromic methods were useful for identification of the facial colliculus in brain stem surgery.
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Affiliation(s)
- K Suzuki
- Department of Neurosurgery, Fukushima Medical School, Japan
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Kim DS, Park YG, Choi JU, Chung SS, Lee KC. An analysis of the natural history of cavernous malformations. SURGICAL NEUROLOGY 1997; 48:9-17; discussion 17-8. [PMID: 9199678 DOI: 10.1016/s0090-3019(96)00425-9] [Citation(s) in RCA: 176] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of cavernous malformations has been controversial. Some reports suggest that surgical resection of the lesion for the prevention of recurrent hemorrhage should not be considered because of low hemorrhagic risk. However, the role of surgery in management of cavernous malformations is undergoing reevaluation. The decision for surgical resection should be based on a careful analysis of the natural history of this lesion, which is not well understood. METHODS We investigated, retrospectively, the natural history of 108 cavernous malformations in 62 patients. Individual cavernous malformations were divided into four categories on the basis of magnetic resonance (MR) findings. The pattern of clinical and radiologic presentation and outcomes of management were analyzed. RESULTS The age of the patients ranged from 4-63 years (mean: 32.2 years). Multiple lesions were found in 13 of 62 patients (21%) and two of these patients were siblings. Twenty-five out of 62 patients had suffered recurrent symptoms. The bleeding rate was 2.3%/person/year (1.4%/lesion/year) during 2509.6 patient years. There were no significant differences between the bleeding rates of each type of lesion. During the follow-up period of 12-48 months (mean: 22.4 months), two of 28 patients conservatively treated had recurrent hemorrhages (rebleeding rate: 3.8%/person/year). During the follow-up period of 12-66 months (mean: 21.7 months), recurrent hemorrhages were observed in two of 17 patients with radiosurgery (rebleeding rate: 7.8%/person/year). CONCLUSION Our study has provided a profile of the natural history of these lesions. Based on our results, we recommend surgical excision of cavernous malformations in those patients with recurrent symptoms or acute progressive symptoms.
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Affiliation(s)
- D S Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
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Pechstein U, Zentner J, Van Roost D, Schramm J. Surgical management of brain-stem cavernomas. Neurosurg Rev 1997; 20:87-93. [PMID: 9226665 DOI: 10.1007/bf01138189] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We present a series of seven patients who were operated on for symptomatic brain-stem cavernomas. The following approaches were used: medial suboccipital (N = 4), lateral suboccipital (N = 1), subtemporal-transtentorial (N = 1), and frontal transcortical-transventricular-subchorioidal-trans velum interpositum (N = 1). Intraoperative motor (N = 4) and somatosensory (N = 1) evoked potential monitoring revealed temporary changes in 3 patients. Immediately postoperatively, the following additional deficits were observed in 6 patients: oculomotor nerve paresis (N = 2), abducens nerve paresis (N = 3), facial nerve paresis (N = 2), deafness (N = 1), and increased ataxia (N = 3). One patient died due to septic complications not related to surgery. After a mean observation time of 2 years, 2 patients had improved, 3 were unchanged, and 1 patient deteriorated as compared to his preoperative status. In conclusion, surgical treatment of brain-stem cavernomas, although carrying a significant risk of temporary neurological deterioration is recommended in symptomatic patients in whom the cavernoma seems to reach the surface of the brain-stem. Intraoperative functional topographic mapping and monitoring have proven useful tools lowering the surgical risks in these patients.
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Affiliation(s)
- U Pechstein
- Department of Neurosurgery, University of Bonn, Fed. Rep. of Germany
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