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Demir MK, Kılıc D, Zorlu E, Kılıc T. Giant Intracranial Cavernous Malformations: A Review on Magnetic Resonance Imaging Characteristics. Indian J Radiol Imaging 2024; 34:511-521. [PMID: 38912256 PMCID: PMC11188748 DOI: 10.1055/s-0044-1779587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Background Intracranial cavernous malformations (CMs), commonly known as cavernomas or cavernous angiomas, are low-flow, well-circumscribed vascular lesions composed of sinusoidal spaces lined by a single layer of endothelium and separated by a collagenous matrix without elastin, smooth muscle, or other vascular wall elements. A diameter greater than 3 cm for a CM is unlikely. These lesions may have atypical appearances on magnetic resonance imaging (MRI). MRI with advanced techniques such as a susceptibility-weighted image or T2-gradient echo, a diffusion-weighted image and corresponding apparent diffusion coefficient map, and diffusion tensor tractography have revolutionized the diagnostic approach to these lesions. Materials and Method The present study reviews the etiopathogenesis, clinical manifestations, MRI strategy, and MRI appearances of the CMs, with a few examples of the giant CMs from our archive. Results Intracranial giant CMs may have unexpected locations, sizes, numbers, and varied imaging appearances due to repeated hemorrhages, unusual enhancement patterns, intense perifocal edema, and unusual associations, making the differential diagnosis difficult. Conclusion Familiarity with the MRI appearances of the giant intracranial CMs and the differential diagnosis improves diagnostic accuracy and patient management.
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Affiliation(s)
- Mustafa Kemal Demir
- Clinic of Radiology, Bahcesehir University Goztepe Medical Park Hospital, Istanbul, Turkey
| | - Deniz Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Emre Zorlu
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
| | - Turker Kılıc
- Department of Neurosurgery, Bahcesehir University School of Medicine, Göztepe Medical Park Hospital, Istanbul, Turkey
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2
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Dumot C, Mantziaris G, Dayawansa S, Xu Z, Pikis S, Peker S, Samanci Y, Ardor GD, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad Eldin RM, Elazzazi AH, Moreno NM, Martínez Álvarez R, Liscak R, May J, Mathieu D, Tourigny JN, Tripathi M, Rajput A, Kumar N, Kaur R, Picozzi P, Franzini A, Speckter H, Hernandez W, Brito A, Warnick RE, Alzate J, Kondziolka D, Bowden GN, Patel S, Sheehan J. Stereotactic radiosurgery for haemorrhagic cerebral cavernous malformation: a multi-institutional, retrospective study. Stroke Vasc Neurol 2024; 9:221-229. [PMID: 37586775 PMCID: PMC11221296 DOI: 10.1136/svn-2023-002380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Cerebral cavernous malformations (CCMs) frequently manifest with haemorrhages. Stereotactic radiosurgery (SRS) has been employed for CCM not suitable for resection. Its effect on reducing haemorrhage risk is still controversial. The aim of this study was to expand on the safety and efficacy of SRS for haemorrhagic CCM. METHODS This retrospective multicentric study included CCM with at least one haemorrhage treated with single-session SRS. The annual haemorrhagic rate (AHR) was calculated before and after SRS. Recurrent event analysis and Cox regression were used to evaluate factors associated with haemorrhage. Adverse radiation effects (AREs) and occurrence of new neurological deficits were recorded. RESULTS The study included 381 patients (median age: 37.5 years (Q1-Q3: 25.8-51.9) with 414 CCMs. The AHR from diagnosis to SRS excluding the first haemorrhage was 11.08 per 100 CCM-years and was reduced to 2.7 per 100 CCM-years after treatment. In recurrent event analysis, SRS, HR 0.27 (95% CI 0.17 to 0.44), p<0.0001 was associated with a decreased risk of haemorrhage, and the presence of developmental venous anomaly (DVA) with an increased risk, HR 1.60 (95% CI 1.07 to 2.40), p=0.022. The cumulative risk of first haemorrhage after SRS was 9.4% (95% CI 6% to 12.6%) at 5 years and 15.6% (95% CI% 9 to 21.8%) at 10 years. Margin doses> 13 Gy, HR 2.27 (95% CI 1.20 to 4.32), p=0.012 and the presence of DVA, HR 2.08 (95% CI 1.00 to 4.31), p=0.049 were factors associated with higher probability of post-SRS haemorrhage. Post-SRS haemorrhage was symptomatic in 22 out of 381 (5.8%) patients, presenting with transient (15/381) or permanent (7/381) neurological deficit. ARE occurred in 11.1% (46/414) CCM and was responsible for transient neurological deficit in 3.9% (15/381) of the patients and permanent deficit in 1.1% (4/381) of the patients. Margin doses >13 Gy and CCM volume >0.7 cc were associated with increased risk of ARE. CONCLUSION Single-session SRS for haemorrhagic CCM is associated with a decrease in haemorrhage rate. Margin doses ≤13 Gy seem advisable.
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Affiliation(s)
- Chloe Dumot
- Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sam Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Gokce D Ardor
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Benha, Egypt
| | - Wael A Reda
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Sameh R Tawadros
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Department of Clinical Oncology, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Departments of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Reem M Emad Eldin
- Gamma-knife Center, Nasser institute Hospital, Cairo, Egypt
- Department of Radiation Oncology, National Cancer Institute, Cairo University, Giza, Egypt
| | - Ahmed H Elazzazi
- Faculty of Medicine, Extended Modular Program, Ain Shams University, Cairo, Egypt
| | | | | | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - David Mathieu
- Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jean-Nicolas Tourigny
- Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | | | - Narendra Kumar
- Radiation Therapy, PGIMER, Chandigarh, Chandigarh, India
| | | | - Piero Picozzi
- Neurosurgery, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - Andrea Franzini
- Neurosurgery, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
| | - Herwin Speckter
- Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Wenceslao Hernandez
- Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Anderson Brito
- Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Ronald E Warnick
- Gamma Knife Center, Mayfield Clinic, The Jewish Hospital - Mercy Health, Cincinnati, Ohio, USA
| | - Juan Alzate
- Neurosurgery, NYU Langone Health, New York, New York, USA
| | | | - Greg N Bowden
- Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Kang SM, Ha BJ, Cheong JH, Ryu JI, Won YD, Han MH. Identification of predictive factors for better outcomes in LINAC-based radiation treatment for cerebral cavernous malformation. Heliyon 2024; 10:e31184. [PMID: 38799755 PMCID: PMC11126848 DOI: 10.1016/j.heliyon.2024.e31184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024] Open
Abstract
The effectiveness of radiation therapy in the treatment of cerebral cavernous malformations (CCM) remains debatable. However, numerous studies have shown a reduction in hemorrhage risk following radiotherapy for CCM. Therefore, herein, we share our experiences utilizing linear accelerator (LINAC)-based radiation for treating CCMs, with the aim of identifying the key factors influencing the therapeutic outcomes. We conducted a retrospective review of all patients with non-brainstem CCMs who underwent radiation treatment, as recorded in the NOVALIS registry at our institution. T2-weighted MR images were used for volumetric assessments using the iPlan radiotherapy planning software. To determine the independent predictors of nidus volume reduction and perilesional brain edema (PBE), we performed multivariate Cox regression analysis to calculate hazard ratios. Twenty patients with 31 non-brainstem CCMs were enrolled in this study. Analysis revealed age as an independent predictive factor for both nidus volume reduction and PBE after radiation treatment for CCM. Furthermore, a single fraction dose of 17 Gy or more was identified as an independent predictor of nidus volume decrease, while a single fraction dose of 18 Gy or more was found to be an independent risk factor for PBE in patients with CCM following LINAC-based radiation therapy. LINAC-based radiation therapy for non-brainstem CCMs with a single fraction radiation dose between 16.5 and 17.5 Gy, or a biologically equivalent dose of approximately 120 Gy, may be the most effective at reducing nidus volume and limiting side effects, particularly in patients under the age of 55 years. We further observed that the risk of PBE increased as the maximum radiation dose delivered to a 1 cc volume of the surrounding normal brain exceeded approximately 17.3 Gy. Therefore, we believe that calculating the D1cc of the normal brain may help to predict the occurrence of PBE when radiotherapy is administered to non-brainstem CCMs.
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Affiliation(s)
| | | | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Je Il Ryu
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Yu Deok Won
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
| | - Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 471-701, Gyonggi-do, South Korea
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Phi JH, Kim SK. Clinical Features and Treatment of Pediatric Cerebral Cavernous Malformations. J Korean Neurosurg Soc 2024; 67:299-307. [PMID: 38547881 PMCID: PMC11079565 DOI: 10.3340/jkns.2024.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Cerebral cavernous malformation (CCM) is a vascular anomaly commonly found in children and young adults. Common clinical presentations of pediatric patients with CCMs include headache, focal neurological deficits, and seizures. Approximately 40% of pediatric patients are asymptomatic. Understanding the natural history of CCM is crucial and hemorrhagic rates are higher in patients with an initial hemorrhagic presentation, whereas it is low in asymptomatic patients. There is a phenomenon known as temporal clustering in which a higher frequency of symptomatic hemorrhages occurs within a few years following the initial hemorrhagic event. Surgical resection remains the mainstay of treatment for pediatric CCMs. Excision of a hemosiderin-laden rim is controversial regarding its impact on epilepsy outcomes. Stereotactic radiosurgery is an alternative treatment, especially for deepseated CCMs, but its true efficacy needs to be verified in a clinical trial.
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Affiliation(s)
- Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
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Fotakopoulos G, Georgakopoulou VE, Papalexis P, Spandidos DA, Trakas N, Sklapani P, Fountas KN. Management of intracranial cavernous malformations using conservative vs. surgical and/or radiosurgical treatment: A systematic review and meta‑analysis. Exp Ther Med 2024; 27:215. [PMID: 38590573 PMCID: PMC11000448 DOI: 10.3892/etm.2024.12503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
Intracranial cavernous malformations (CMs) are vascular lesions with a high bleeding rate. At present, the debate regarding their treatment is still ongoing. The present systematic review and meta-analysis aimed to evaluate the safety of surgery or radiosurgery (SRS) for the management of CMs and to determine their potential outcomes compared with conservative treatment. The present systematic review and meta-analysis investigated the relative articles involving the management of intracranial CMs, namely their natural history (conservative treatment) vs. surgical/SRS treatment through electronic databases until June, 2023. The collected variables included the first author's name, the study period covered, the year of publication, the total number of patients examined and their age, and the number of males. In total, six articles met the eligibility criteria. The total number of patients was 399 (157 in the surgery/SRS group and 242 in the conservative treatment group). The results revealed that surgical or SRS management is a safe procedure for CMs compared with conservative treatment. Notably, the use of hemosiderin in the pre-MRI, the free of seizures parameter and the neurological deficit parameters were associated with improved outcomes in the surgical or SRS group of patients.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Petros Papalexis
- Unit of Endocrinology, First Department of Propedeutic and Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Tasiou A, Brotis AG, Kalogeras A, Tzerefos C. Cavernous malformations of the central nervous system: An international consensus statement. BRAIN & SPINE 2023; 3:102707. [PMID: 38020995 PMCID: PMC10668094 DOI: 10.1016/j.bas.2023.102707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Adamantios Kalogeras
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
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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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Berber T, Celik SE, Aksaray F, Yoney A, Harmanci K, Tambas M, Yılmaz BD, Numanoglu C, Yolcu A, Açan Hİ, Dinçer ST, Yıldırım BA. Radiosurgery effects and adverse effects in symptomatic eloquent brain-located Cavernomas. JOURNAL OF RADIATION RESEARCH 2023; 64:133-141. [PMID: 36208871 PMCID: PMC9855324 DOI: 10.1093/jrr/rrac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Indexed: 06/16/2023]
Abstract
In this study, the dose schedule efficacy, safety and late adverse effects of stereotactic radiosurgery (SRS) were evaluated for patients with symptomatic cavernomas who were not eligible for surgery and treated with SRS. Between January 2013 and December 2018, 53 patients with cavernomas were treated using SRS with the CyberKnife® system. Patients' diseases were deeply located or were in subcortical functional brain regions. In addition to bleeding, 23 (43.4%) patients had epilepsy, 12 (22.6%) had neurologic symptoms and 16 patients (30.2%) had severe headaches. The median volume was 741 (range, 421-1351) mm3, and the median dose was 15 (range, 14-16) Gy in one fraction. After treatment, six (50%) of 12 patients with neurologic deficits still had deficits. Rebleeding after treatment developed in only two (3.8%) patients. The drug was completely stopped in 14 (60.9%) out of 23 patients who received epilepsy treatment, and the dose of levetiracetam decreased from 2000 mg to 1000 mg in four (17.3%) of nine patients. Radiologically, complete response (CR) was observed in 13 (24.5%) patients, and partial responses (PR) were observed in 32 (60.2%) patients. Clinical response of CR was observed in 30 (56.6%) patients, PR was observed in 16 (30.2%), stable disease (SD) was observed in three (5.7%) and four (7.5%) patients progressed. In conclusion, SRS applied in the appropriate dose schedule may be an effective and reliable method in terms of symptom control and prevention of rebleeding, especially in patients with inoperable cavernomas.
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Affiliation(s)
- Tanju Berber
- Corresponding author. Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Kaptan Pasa, SSK Okmeydani Hst. No: 25, 34384 Sisli/Istanbul, Turkey. Tel: +905324111202;
| | - Suat Erol Celik
- Department of Neurosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ferdi Aksaray
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Adnan Yoney
- Department of Internal Medicine, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Kemal Harmanci
- Department of Radiology, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Makbule Tambas
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Binnur Dönmez Yılmaz
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Cakir Numanoglu
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Ahmet Yolcu
- Department of Radiation Oncology, Namık Kemal University Medical Faculty of Medicine, Tekirdag, Turkey
| | - Hilal İrem Açan
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Selvi Tabak Dinçer
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology and Radiosurgery, Okmeydani Training And Research Hospital, Istanbul, Turkey
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KUWANO A, YAMAGUCHI K, FUNATSU T, MOTEKI Y, EGUCHI S, MIURA I, UCHIDA M, ITO K, ISHIKAWA T, KAWAMATA T. A Case of Cavernous Malformation of the Midbrain Removed via an Interhemispheric Transcallosal Subchoroidal Approach. NMC Case Rep J 2022; 9:337-342. [PMID: 36381135 PMCID: PMC9633092 DOI: 10.2176/jns-nmc.2022-0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/11/2022] [Indexed: 11/05/2022] Open
Abstract
Cavernous malformations of the midbrain have a higher rate of hemorrhage and a poorer prognosis than vascular malformations of other brain areas. Surgical resection of these lesions is often necessary to avoid neurological deficits in affected patients. Herein, the literature surrounding cavernous malformations was examined, and the case of a 48-year-old man with left hemiparesis and diplopia caused by incomplete right oculomotor nerve palsy, who was diagnosed with a hemorrhage from a midbrain cavernous malformation, was discussed. The lesion expanded gradually on magnetic resonance imaging and was symptomatic; radical removal of the lesion before the onset of irreversible symptoms due to recurring bleeding was therefore considered to be beneficial for the patient. Surgical removal of the entire cavernous malformations of the midbrain was performed using an interhemispheric transcallosal subchoroidal approach, with excellent postoperative results and complete recovery from the oculomotor nerve palsy and left hemiparesis. This case shows that this approach is the most appropriate for surgical resections of lesions in the upper midbrain.
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Affiliation(s)
- Atsushi KUWANO
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Koji YAMAGUCHI
- Department of Neurosurgery, Tokyo Women's Medical University
| | | | - Yosuke MOTEKI
- Department of Neurosurgery, Tokyo Women's Medical University
| | | | - Isamu MIURA
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Momo UCHIDA
- Department of Neurosurgery, Tokyo Women's Medical University
| | - Kaname ITO
- Department of Neurosurgery, Tokyo Women's Medical University
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10
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Gamma Knife® stereotactic radiosurgery for intracranial cavernous malformations. J Clin Neurosci 2022; 106:96-102. [DOI: 10.1016/j.jocn.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
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11
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Shim Y, Phi JH, Wang KC, Cho BK, Lee JY, Koh EJ, Kim KH, Lee EJ, Kim KJ, Kim SK. Clinical outcomes of pediatric cerebral cavernous malformation: an analysis of 124 consecutive cases. J Neurosurg Pediatr 2022; 30:474-483. [PMID: 36057124 DOI: 10.3171/2022.7.peds22299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE One-fourth of cerebral cavernous malformation (CCM) patients are children, but studies on these patients are scarce. This study aimed to identify the clinical presentation of pediatric CCM patients and to investigate clinical outcomes according to the treatment modalities applied on the basis of our institution's treatment strategy. METHODS The authors performed a retrospective analysis of 124 pediatric CCM patients with a follow-up of more than 1 year from 2000 to 2019. They performed resection (n = 62) on lesions causing intractable seizure, rebleeding, or mass effect and observed the clinical courses of patients with lesions in deep or eloquent areas without persistent symptoms (n = 52). Radiosurgery (n = 10) was performed when the patient refused resection or strongly desired radiosurgery. The authors investigated the clinical characteristics, performance status (modified Rankin Scale [mRS] score), and rebleeding rate at the 1-year and last follow-up examinations and compared these among 3 groups classified on the basis of treatment applied. The authors evaluated seizure outcomes at the 1-year and last follow-up examinations for the surgery (n = 32) and observation (n = 17) groups. Finally, the authors drew cumulative incidence curves for the discontinuation of antiepileptic drugs (AEDs) for patients in the surgery (n = 30) and observation (n = 9) groups. RESULTS The 3 groups showed slight differences in initial symptoms, lesion locations, and rates of recent hemorrhage. The proportion of patients with improved mRS score at the 1-year follow-up was significantly greater in the surgery group than in the other groups (67% of the surgery group, 52% observation group, and 40% radiosurgery group; p = 0.078), as well as at the last follow-up (73% surgery group, 54% observation group, and 60% radiosurgery group; p = 0.097). The surgery group also had the lowest rebleeding rate during the follow-up period (2% surgery group, 11% observation group, and 20% radiosurgery group; p = 0.021). At the 1-year follow-up, the proportion of seizure-free patients without AEDs was significantly higher in the surgery group than the observation group (88% surgery group vs 53% observation group, p < 0.001), and similar results were obtained at the last follow-up (91% surgery group vs 56% observation group, p = 0.05). The 5-year AED-free rates for the surgery and observation groups were 94% and 50%, respectively, on the cumulative incidence curve (p = 0.049). CONCLUSIONS The clinical presentation of pediatric CCM patients was not significantly different from that of adult patients. Lesionectomy may be acceptable for pediatric CCM patients with indications of persistent seizures despite AED medications, rebleeding, and mass effects.
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Affiliation(s)
- Youngbo Shim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Phi
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Chang Wang
- 2Neuro-oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Republic of Korea
| | - Byung-Kyu Cho
- 3Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Ji Yeoun Lee
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- 4Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Koh
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hyun Kim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Jung Lee
- 5Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Joong Kim
- 6Division of Pediatric Neurology, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; and
| | - Seung-Ki Kim
- 1Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- 7Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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12
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Samanci Y, Ardor GD, Peker S. Management of pediatric cerebral cavernous malformations with gamma knife radiosurgery: a report of 46 cases. Childs Nerv Syst 2022; 38:929-938. [PMID: 35275282 DOI: 10.1007/s00381-022-05485-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pediatric cerebral cavernous malformations (CCMs) are commonly treated vascular anomalies with different clinical characteristics than their adult counterparts. Outcomes of Gamma Knife Radiosurgery (GKRS) for pediatric CCMs have not explicitly been reported. This paper reports our experience in managing pediatric CCMs with GKRS. METHODS We retrospectively reviewed the clinical features, GKRS parameters, and clinical and radiological outcomes of 46 children with 64 CCMs. RESULTS A total of 46 children, including 19 girls and 27 boys, with a median age of 16 years (3-17 years), were enrolled in the study. The median age at first CCM diagnosis was 13 years (range, 2-17 years). Twenty-two patients (47.8%) had more than one neurological symptom at the time of diagnosis, and the most common presenting symptom was seizure (28.3%). The most common location was supratentorial superficial (53.1%), and 17.4% of patients had multiple CCMs. A developmental venous anomaly was detected in 5 patients (10.9%). During a total of 52.4 retrospective patient-years in patients with > 1 hemorrhage episode, the calculated annual hemorrhage rate was 40.1%. The median post-GKRS follow-up was 79 months (range, 19-175 months), with an overall 306.2 prospective patient years. The annual hemorrhage rate (AHR) during the first 2 years after GKRS and after the initial 2 years was 1.11% and 0.46%, respectively. Regarding clinical factors and GKRS parameters, univariate analysis revealed a significant association with post-GKRS AHR and volume (p = 0.023) only. Patients with pre-GKRS seizures showed favorable seizure control (Engel class I and II) in 8 children (61.5%). There was no mortality in our series. CONCLUSION Low AHR following GKRS with no radiation-induced toxicity makes GKRS a therapeutic alternative for pediatric CCMs.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koç University Hospital, Istanbul, Turkey.,Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Gokce Deniz Ardor
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Gamma Knife Center, Koç University Hospital, Istanbul, Turkey. .,School of Medicine, Department of Neurosurgery, Koç University, Davutpasa Caddesi No: 4, 34010, Zeytinburnu, Istanbul, Turkey.
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13
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Karaaslan B, Gülsuna B, Erol G, Dağli Ö, Emmez H, Kurt G, Çeltikçi E, Börcek AÖ. Stereotactic radiosurgery for cerebral cavernous malformation: comparison of hemorrhage rates before and after stereotactic radiosurgery. J Neurosurg 2022; 136:655-661. [PMID: 34450585 DOI: 10.3171/2021.2.jns21138] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/15/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Cerebral cavernous malformation (CM) is an angiographically occult vascular pathology. Although microsurgery is the gold standard treatment to control the symptoms of CM, resection carries high risk in some situations, especially eloquent areas. The objective was to evaluate annual hemorrhage rates (AHRs) before and after stereotactic radiosurgery (SRS) treatment of cerebral CM in different locations. METHODS A total of 195 patients (119 women and 76 men) with CM treated at the Gazi University Gamma Knife Center between April 2005 and June 2017 were analyzed. The mean ± SD follow-up period was 67.4 ± 31.1 months (range 12 days to 170 months). AHR before SRS, AHR after SRS, morbidity associated with radiation, seizure control rate after SRS, lesion volume, coexistence with developmental venous anomaly, and SRS treatment parameters were analyzed, with evaluation of radiological data and clinical charts performed retrospectively. The seizure control rate was assessed using the Engel outcome scale. RESULTS The AHR before SRS was 15.3%. Application of SRS to these patients significantly reduced the AHR rates to 2.6% during the first 2 years after treatment and to 1.4% thereafter. Favorable seizure control (Engel class I and II) after radiosurgery was achieved in 23 patients (88.5%) with epilepsy. Radiation-related temporary complications occurred in 15.4% of patients, and permanent morbidity occurred in 4.6%. CONCLUSIONS SRS is a safe and effective treatment modality for reducing the hemorrhage risk of CM. The authors suggest that SRS should be considered for the treatment of patients with CM, high surgical risks, and hemorrhage history, instead of a using a wait-and-see policy.
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Affiliation(s)
- Burak Karaaslan
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Beste Gülsuna
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Gökberk Erol
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Özlem Dağli
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Hakan Emmez
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Gökhan Kurt
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Emrah Çeltikçi
- 1Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey; and
| | - Alp Özgün Börcek
- 2Division of Pediatric Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
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14
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Ganz JC. Cavernous malformations. PROGRESS IN BRAIN RESEARCH 2022; 268:115-132. [PMID: 35074077 DOI: 10.1016/bs.pbr.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cavernous malformations are relatively common intracerebral malformations of which we only became properly aware after the introduction of MRI. They may be sporadic or familial. Familial CMs may be multiple and new lesions appear over time requiring intermittent MR control. Many sporadic CMs have no symptoms. The commonest location is in the supratentorial cerebral parenchyma presenting with epilepsy. The best treatment is microsurgery. A small proportion are in the brainstem and may rebleed and even be lethal. Treatment includes microsurgery and radiosurgery. Microsurgery cures the patient but has substantial problems with complications, deterioration and partial removal. Radiosurgery has taken time to demonstrate that it can over 2 years substantially reduce the risk of rebleeds without the risks of microsurgery. Both methods have a part to play in the treatment.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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15
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Robert SM, Chiang VL. Commentary: Feasibility and Morbidity of Magnetic Resonance Imaging-Guided Stereotactic Laser Ablation of Deep Cerebral Cavernous Malformations: A Report of 4 Cases. Neurosurgery 2021; 89:E209-E210. [PMID: 34293138 DOI: 10.1093/neuros/nyab262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/10/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stephanie M Robert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Veronica L Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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16
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Hu YJ, Zhang LF, Ding C, Tian Y, Chen J. Gamma Knife Radiosurgery for Cavernous Malformations of Basal Ganglia and Thalamus: A Retrospective Study of 53 Patients. Stereotact Funct Neurosurg 2021; 99:273-280. [PMID: 34107485 DOI: 10.1159/000510108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/10/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Gamma Knife radiosurgery (GKRS) has been used to treat cavernous malformations (CMs) located in basal ganglia and thalamus. However, previous reports are limited by small patient population. METHODS We retrospectively reviewed the clinical and radiological data of 53 patients with CMs of basal ganglia and thalamus who underwent GKRS at West China Hospital between May 2009 and July 2018. All patients suffered at least once bleeding before GKRS. The mean volume of these lesions was 1.77 cm3, and the mean marginal dose was 13.2 Gy. After treatment, patients were followed to determine the change in symptom and hemorrhage event. RESULTS The mean follow-up period was 52.1 months (6.2-104.3 months). The calculated annual hemorrhage rate (AHR) was 48.5% prior to GKRS and 3.0% after treatment (p < 0.001). The Kaplan-Meier analysis revealed that 2-, 3-, and 5-year hemorrhage-free survival were 88, 80.9, and 80.9%, respectively. Preexisting symptoms were resolved in 11 patients, improved in 14, and stable in 5. Only 2 patients (3.8%) developed new neurological deficit. CONCLUSION Our study suggests that AHR after GKRS was comparable to the recorded AHR of natural history (3.1-4.1%) in previous studies. GKRS is a safe and effective treatment modality for CMs of basal ganglia and thalamus. Considering the relative insufficient understanding of natural history of CMs, future study warrants longer follow-up.
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Affiliation(s)
- Yan-Jia Hu
- Department of Neurosurgery, Sichuan University West China Hospital, Chengdu, China,
| | - Li-Feng Zhang
- Department of Neurosurgery, Sichuan University West China Hospital, Chengdu, China
| | - Chang Ding
- Department of Neurosurgery, Sichuan University West China Hospital, Chengdu, China
| | - Yuan Tian
- Department of Neurosurgery, Sichuan University West China Hospital, Chengdu, China
| | - Jing Chen
- Department of Neurosurgery, Sichuan University West China Hospital, Chengdu, China
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17
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Lee CC, Wang WH, Yang HC, Lin CJ, Wu HM, Lin YY, Hu YS, Chen CJ, Chen YW, Chou CC, Liu YT, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Hsu SPC. Gamma Knife radiosurgery for cerebral cavernous malformation. Sci Rep 2019; 9:19743. [PMID: 31874979 PMCID: PMC6930272 DOI: 10.1038/s41598-019-56119-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022] Open
Abstract
This is a retrospective study examining the efficacy and safety of Gamma Knife radiosurgery (GKS) in treating patients with cerebral cavernous malformations (CCMs). Between 1993 and 2018, 261 patients with 331 symptomatic CCMs were treated by GKS. The median age was 39.9 years and females were predominant (54%). The median volume of CCMs was 3.1 mL. The median margin dose was 11.9 Gy treat to a median isodose level of 59%. Median clinical and imaging follow-up times were 69 and 61 months, respectively. After the initial hemorrhage that led to CCM diagnosis, 136 hemorrhages occurred in the period prior to GKS (annual incidence = 23.6%). After GKS, 15 symptomatic hemorrhages occurred within the first 2 years of follow-up (annual incidence = 3.22%), and 37 symptomatic hemorrhages occurred after the first 2 years of follow-up (annual incidence = 3.16%). Symptomatic radiation-induced complication was encountered in 8 patients (3.1%). Mortality related to GKS occurred in 1 patient (0.4%). In conclusion, GKS decreased the risk of hemorrhage in CCM patients presenting with symptomatic hemorrhage. GKS is a viable alternative treatment option for patients with surgically-inaccessible CCMs or significant medical comorbidities.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Hsin Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Yu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Chen Chou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yo-Tsen Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sanford P C Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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18
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Dawley T, Rajah G, Kupsky W, Haridas A. Rapidly Expanding Pediatric Post Radiation Brainstem Cavernoma Presenting with Singultus. Cureus 2019; 11:e4157. [PMID: 31058040 PMCID: PMC6488447 DOI: 10.7759/cureus.4157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Here we present a pediatric patient status post resection of a primitive neuroectodermal tumor (PNET) with cranial/spinal radiation and development of a medullary cavernoma seven years after radiation therapy. The patient’s cavernoma demonstrated rapid symptomatic growth in six weeks resulting in the presentation of intractable hiccups (singultus). The patient underwent resection of the cavernoma with cessation of the hiccups. We also review the pathology and possible mechanisms of such rapid growth of this post-radiation cavernoma as well as advise surveillance for patients with such lesions, as their course may be different from that of sporadic cavernomas.
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Affiliation(s)
- Troy Dawley
- Neurosurgery, St. John Providence Hospital, Southfield, USA
| | - Gary Rajah
- Neurosurgery, Wayne State University School of Medicine, Detroit, USA
| | - William Kupsky
- Pathology, Wayne State University School of Medicine, Detroit, USA
| | - Abilash Haridas
- Neurosurgery, Wayne State University School of Medicine, Detroit, USA
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19
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Maish WN. Developmental venous anomalies and brainstem cavernous malformations: a proposed physiological mechanism for haemorrhage. Neurosurg Rev 2018; 42:663-670. [PMID: 30291476 DOI: 10.1007/s10143-018-1039-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/26/2018] [Indexed: 01/28/2023]
Abstract
The incidental diagnosis of both developmental venous anomalies (DVAs) and cavernous malformations (CMs) in the central nervous system is increasing with improved imaging techniques. While classically silent diseases, these cerebrovascular pathologies can follow an aggressive course, particularly when present in the brainstem. In the last decade, substantial research has focussed on KRIT1-mediated tight junction gene expression and their role in CM development. However, our understanding of the physiologic conditions precipitating symptomatic CM development or CM haemorrhage with and without concomitant DVAs, remains lacking. The only established risk factor for CM haemorrhage is a previous history of haemorrhage, and literature currently reports trauma as the only precipitant for symptomatic events. While plausible, this occurs in a minority, with many patients experiencing occult events. This manuscript presents a hypothesis for symptomatic CM events by first discussing the anatomical pathways for intracranial venous outflow via the internal jugular veins (IJV) and vertebral venous plexus (VVP), then exploring the role of venous flow diversion away from the IJVs under physiologic stress during dynamic postural shift. The resultant increase in intracranial venous pressure can exacerbate normal and pre-existing structural DVA pathologies, with repeated exposure causing symptomatic or CM-inducing events. This pathophysiological model is considered in the context of the role of the autonomic nervous system (ANS) in postural intracranial venous outflow diversion, and how this may increase the risk of DVA or CM events. It is hoped that this hypothesis invokes further investigation into precipitants for DVA or CM events and their sequela and, also, furthers the current knowledge on pathophysiological development of DVAs and CMs.
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Affiliation(s)
- William N Maish
- Australian National University Medical School, Building 4, The Canberra Hospital, Hospital Road, Garran, ACT, 2605, Australia.
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20
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Singh H, Elarjani T, da Silva HB, Shetty R, Kim L, Sekhar LN. Brain Stem Cavernous Malformations: Operative Nuances of a Less-Invasive Resection Technique. Oper Neurosurg (Hagerstown) 2018; 15:153-173. [PMID: 29228395 DOI: 10.1093/ons/opx231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/27/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Different operative techniques are reported for the resection of brainstem cavernous malformations (BSCMs). The senior author has previously reported on a less-invasive technique of entering the brain stem with piecemeal removal of BSCMs, especially the deep-seated ones. OBJECTIVE To present a larger series of these lesions, emphasizing the approach to the brain stem via case selection. We discuss the nuances of the less-invasive operative technique through case illustrations and intraoperative videos. METHODS A retrospective review of 46 consecutive cases of BSCMs, with their clinical and radiographic data, was performed. Nine cases were selected to illustrate 7 different operative approaches, and discuss surgical nuances of the less-invasive technique unique to each. RESULTS Postoperative morbidity, defined as an increase in modified Rankin Scale, was observed in 5 patients (10.9%). A residual BSCM was present in 2 patients (4.3%); both underwent reoperation to remove the remainder. At follow-up of 31.1 ± 27.8 mo, 3 patients experienced recurrence (6.5%). Overall, 65% of our patients improved, 20% stayed the same, and 11% worsened postsurgery. Two patients died, yielding a mortality of 4.3%. CONCLUSION Using the less-invasive resection technique for piecemeal BSCM removal, in appropriately selected patients, has yielded comparable to improved patient outcomes over existing large series. In our experience, lateral, anterolateral, and posterolateral approaches are favorable over direct midline (dorsal or ventral) approaches. A thorough understanding of brain-stem safe-entry zones, in conjunction with appropriate approach selection, is key to a good outcome in challenging cases.
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Affiliation(s)
- Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Turki Elarjani
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Harley Brito da Silva
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Rakshith Shetty
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Louis Kim
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, Washington
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21
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Nagy G, Stokes SS, Erőss LG, Bhattacharyya D, Yianni J, Rowe JG, Kemeny AA, Radatz MWR. Contemporary radiosurgery of cerebral cavernous malformations: Part 2. Treatment outcome for hemispheric lesions. J Neurosurg 2018; 130:1826-1834. [PMID: 30052157 DOI: 10.3171/2018.2.jns171267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of radiosurgery (RS) in treating superficial cavernous malformations (CMs) is insufficiently studied in part because of the disappointing results of early experimental attempts as compared to the mostly safe and effective microsurgery. Nonetheless, because of lesion- or treatment-specific factors, a therapeutic alternative may be required. In this study, the authors aimed to assess the safety of RS in treating superficial CMs and to analyze its long-term effect on hemorrhage rates and epilepsy control. METHODS The authors conducted a retrospective analysis of 96 patients with 109 CMs located in the cerebral or cerebellar hemispheres and treated with RS between 1995 and 2014. A median of 15 Gy (range 10-25 Gy) was given to the 50% prescription isodose level, lesion volume was 604 mm3 (4-8300 mm3), and the prescription isodose volume was 638.5 mm3 (4-9500 mm3). Outcomes were compared to those of 206 deep-seated lesions reported on in another study. Ninety-five patients had available follow-up, which was a median of 7 years (1-21 years). Median patient age was 42 years (0.5-77) at presentation and 45 (3-80) at treatment. Seventy-one CMs presented with symptomatic hemorrhage, and 52 caused seizures. RESULTS In the nonhemorrhagic group (37 lesions), one bleed occurred during the follow-up period, for an annual bleed rate of 0.4% per lesion. The lifetime annual bleed rate of CMs having a single hemorrhage prior to treatment was 2.5%. The rebleed rate in the single-bleed group decreased from 1.8% within the first 2 years after RS to 0.7% thereafter. The pretreatment rebleed rate for lesions having multiple bleeds prior to RS was 14.15%, which fell to 3.85% for the first 2 years after RS and declined to 1.3% thereafter. Multivariate analysis showed younger age, deep lesion location, and multiple pretreatment hemorrhages as significant predictors of posttreatment hemorrhage.Pretreatment hemorrhages led to permanent deficits in 41.4% of the cases with a single bleed and in 46.1% of cases with multiple bleeds. Only mild (modified Rankin Scale score 1) and a low rate of permanent neurological deficits were caused either by posttreatment hemorrhages (4.3%) or by radiation (2%).The rate of improvement in epilepsy was 84.9% after RS in patients with at least one seizure prior to treatment, not depending on the presence of hemorrhage or the time interval between presentation and treatment. Favorable outcome occurred in 81% of patients whose seizures were not controlled with antiepileptic medication prior to RS. CONCLUSIONS Radiosurgery for superficial CMs is safe and appears to be effective, offering a real treatment alternative to surgery for selected patients. Given their relatively benign natural history, superficial CMs require further study to verify the long-term benefit of RS over the lesions' natural history.
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Affiliation(s)
- Gábor Nagy
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | | | - Loránd G Erőss
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Debapriya Bhattacharyya
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - John Yianni
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
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22
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Nagy G, Burkitt W, Stokes SS, Bhattacharyya D, Yianni J, Rowe JG, Kemeny AA, Radatz MWR. Contemporary radiosurgery of cerebral cavernous malformations: Part 1. Treatment outcome for critically located hemorrhagic lesions. J Neurosurg 2018; 130:1817-1825. [PMID: 30052154 DOI: 10.3171/2017.5.jns17776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term benefits of radiosurgery (RS) applying modern protocols to treat cavernous malformations (CMs) remain unclear as critics may consider the decrease in the rebleed rate generally observed 2 years after RS as a reflection of the lesion's natural history. The authors adopted an early intention-to-treat attitude since rehemorrhage from deep-seated CMs ultimately leads to stepwise neurological deterioration. The safety of this early policy was previously demonstrated. Here, the authors revisit their current practice in a larger population with a longer follow-up time to assess the long-term effects of RS in the context of current knowledge on the natural history of CMs. METHODS The authors conducted a retrospective analysis of 210 patients with 210 hemorrhagic CMs located in the brainstem, thalamus, or basal ganglia and treated with Gamma Knife RS between 1995 and 2014. Two hundred six patients had available follow-up, which was a median of 5.5 years (range 1-20 years). The median age was 37 years (0.5-77 years) at presentation and 43 (2-78) at treatment. One hundred twenty-seven CMs had bled once and 83 had had multiple hemorrhages prior to treatment. RESULTS The lifetime annual bleed rate of CMs having a single hemorrhage prior to treatment was 2.4% per lesion. The hemorrhage rate stabilized at 1.1% after a temporary increase of 4.3% within the first 2 years after RS. The annual pretreatment hemorrhage rate was 2.8% for the lesions having multiple bleeds prior to RS with a pretreatment rebleed rate of 20.7% and with a modest gradual decrease within the first 5 years and remaining stable at 11.55% thereafter. The rebleed rate fell to 7.9% for the first 2 years after RS and declined further to 1.3% thereafter, which was significantly lower than the long-term pretreatment rebleed risk. The rate of hemorrhage-free survival remained 86.4% and 75.1% (1 patient each) at 20 years after RS in the single- and multiple-bleed groups, respectively.Pretreatment hemorrhages resulted in permanent deficits in 48.8% of the cases with a single bleed and in 77.1% of the cases with multiple bleeds. Both the rate and severity of deficits were significantly lower in the first group. Only mild and a low rate of permanent neurological deficits were caused either by posttreatment hemorrhages (7.4%) or by radiation (7.2%). The rate of persistent morbidity in the single-bleed group remained significantly lower at the end of the study than pretreatment morbidity in the multiple-bleed group (OR 2.9, 95% CI 1.6-5.3). Lesion-specific mortality was < 1%. CONCLUSIONS The hemorrhage rate of CMs after RS remained low after the first 2 years during the longer follow-up period. The benefit of early treatment appears to be confirmed by the study results as repeated hemorrhages carry the risk of significantly higher cumulative morbidity than the morbidity associated with RS.
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Affiliation(s)
- Gábor Nagy
- 1National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Wendy Burkitt
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
| | | | - Debapriya Bhattacharyya
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - John Yianni
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- 2Department of Neurosurgery, and
- 3National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital; and
- 4Thornbury Radiosurgery Centre, Sheffield, United Kingdom
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Affiliation(s)
- Christopher J Stapleton
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Fred G Barker
- From the Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston.
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López-Serrano R, Martínez NE, Kusak ME, Quirós A, Martínez R. Significant Hemorrhage Rate Reduction after Gamma Knife Radiosurgery in Symptomatic Cavernous Malformations: Long-Term Outcome in 95 Case Series and Literature Review. Stereotact Funct Neurosurg 2017; 95:369-378. [DOI: 10.1159/000480664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/23/2017] [Indexed: 11/19/2022]
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25
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Tian KB, Zheng JJ, Ma JP, Hao SY, Wang L, Zhang LW, Wu Z, Zhang JT, Li D. Clinical course of untreated thalamic cavernous malformations: hemorrhage risk and neurological outcomes. J Neurosurg 2016; 127:480-491. [PMID: 27834594 DOI: 10.3171/2016.8.jns16934] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The natural history of cerebral cavernous malformations (CMs) has been widely studied, but the clinical course of untreated thalamic CMs is largely unknown. Hemorrhage of these lesions can be devastating. The authors undertook this study to obtain a prospective hemorrhage rate and provide a better understanding of the prognosis of untreated thalamic CMs. METHODS This longitudinal cohort study included patients with thalamic CMs who were diagnosed between 2000 and 2015. Clinical data were recorded, radiological studies were extensively reviewed, and follow-up evaluations were performed. RESULTS A total of 121 patients were included in the study (56.2% female), with a mean follow-up duration of 3.6 years. The overall annual hemorrhage rate (subsequent to the initial presentation) was calculated to be 9.7% based on the occurrence of 42 hemorrhages over 433.1 patient-years. This rate was highest in patients (n = 87) who initially presented with hemorrhage and focal neurological deficits (FNDs) (14.1%) (χ2 = 15.358, p < 0.001), followed by patients (n = 19) with hemorrhage but without FND (4.5%) and patients (n = 15) without hemorrhage regardless of symptoms (1.2%). The initial patient presentations of hemorrhage with FND (hazard ratio [HR] 2.767, 95% CI 1.336-5.731, p = 0.006) and associated developmental venous anomaly (DVA) (HR 2.510, 95% CI 1.275-4.942, p = 0.008) were identified as independent hemorrhage risk factors. The annual hemorrhage rate was significantly higher in patients with hemorrhagic pres entation at diagnosis (11.7%, p = 0.004) or DVA (15.7%, p = 0.002). Compared with the modified Rankin Scale (mRS) score at diagnosis (mean 2.2), the final mRS score (mean 2.0) was improved in 37 patients (30.6%), stable in 59 patients (48.8%), and worse in 25 patients (20.7%). Lesion size (odds ratio [OR] per 0.1 cm increase 3.410, 95% CI 1.272-9.146, p = 0.015) and mRS score at diagnosis (OR per 1 point increase 3.548, 95% CI 1.815-6.937, p < 0.001) were independent adverse risk factors for poor neurological outcome (mRS score ≥ 2). Patients experiencing hemorrhage after the initial ictus (OR per 1 ictus increase 6.923, 95% CI 3.023-15.855, p < 0.001) had a greater chance of worsened neurological status. CONCLUSIONS This study verified the adverse predictors for hemorrhage and functional outcomes of thalamic CMs and demonstrated an overall annual symptomatic hemorrhage rate of 9.7% after the initial presentation. These findings and the mode of initial presentation are useful for clinicians and patients when selecting an appropriate treatment, although the tertiary referral bias of the series should be taken into account.
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Affiliation(s)
- Kai-Bing Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jing-Jie Zheng
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jun-Peng Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Shu-Yu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
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Park SJ, Park SH. Systemic Expression of Vascular Endothelial Growth Factor in Patients with Cerebral Cavernous Malformation Treated by Stereotactic Radiosurgery. J Korean Neurosurg Soc 2016; 59:442-8. [PMID: 27651861 PMCID: PMC5028603 DOI: 10.3340/jkns.2016.59.5.442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/11/2016] [Accepted: 04/07/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Increased expression of angiogenic factors, such as vascular endothelial growth factor (VEGF), is associated with the pathogenesis of cerebral cavernous malformations (CCMs). The purpose of this study was to investigate plasma levels of VEGF in normal subjects and in patients with CCM and to evaluate change in these levels following stereotactic radiosurgery (SRS). METHODS Peripheral venous blood was collected from 6 patients with CCM before SRS using Gamma Knife and at the 1 week, 1 month, 3month, and 6 month follow-up visits. Plasma VEGF levels were measured using commercially available enzyme-linked immunosorbent assay kits. Peripheral blood samples were obtained from 10 healthy volunteers as controls. RESULTS Mean plasma VEGF level of 41.9 pg/mL (range, 11.7-114.9 pg/mL) in patients with CCM at baseline was higher than that of the healthy controls (29.3 pg/mL, range, 9.2-64.3 pg/mL), without significant differences between CCM patients and controls (p=0.828). Plasma VEGF level following SRS dropped to 24.6 pg/mL after 1 week, and decreased to 18.5 pg/mL after 1 month, then increased to 24.3 pg/mL after 3 months, and 32.6 pg/mL after 6 months. Two patients suffering from rebleeding after SRS showed a higher level of VEGF at 6 months after SRS than their pretreatment level. CONCLUSION Plasma VEGF levels in patients with CCM were elevated over controls at baseline, and decreased from baseline to 1 month after SRS and increased further for up to 6 months. Theses results indicated that anti-angiogenic effect of SRS might play a role in the treatment of CCMs.
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Affiliation(s)
- Sang-Jin Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
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Endoscopic Endonasal Transclival Resection of a Brainstem Cavernoma: A Detailed Account of Our Technique and Comparison with the Literature. World Neurosurg 2015; 84:2064-71. [PMID: 26341427 DOI: 10.1016/j.wneu.2015.08.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report a technique of endoscopic transclival resection of a hemorrhagic brainstem cavernous malformation manifesting in the ventral pons. METHODS A 29-year-old woman presented with numbness and tingling of the right arm and leg and loss of fine motor control. Magnetic resonance imaging revealed a cavernoma in the ventromedial brainstem on the ventral surface. A purely endoscopic, endonasal, transclival approach was used to resect this cavernoma. Computed tomography/magnetic resonance imaging merged navigation (StealthStation, Medtronic) was used. RESULTS The patient had no neurologic deficits postoperatively. The motor control loss and tingling disappeared. She did not experience any complications. Cerebrospinal fluid leakage appeared to result from using the very small opening of the skull base and dura mater and was the reason for the use of a lumbar drain for several days. At the 6-week follow-up examination, the patient was in excellent condition with no neurologic deficits and had returned to her full-time job. CONCLUSIONS Successful endoscopic, endonasal, transclival resection of a brainstem cavernous malformation was described. This patient experienced improvement in neurologic symptoms after surgery without morbidity. Technologic advances in endoscopic skull base approaches provide access to lesions of the brainstem that previously required more invasive approaches. The endonasal transclival approach provides the most direct route to ventral pontine lesions. Early intervention in brainstem cavernous malformation is indicated and should be performed with an individualized approach taking into consideration the possible complications.
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Affiliation(s)
- Jason Sheehan
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Departments of 1 Neurological Surgery and
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Shin SS, Murdoch G, Hamilton RL, Faraji AH, Kano H, Zwagerman NT, Gardner PA, Lunsford LD, Friedlander RM. Pathological response of cavernous malformations following radiosurgery. J Neurosurg 2015; 123:938-44. [PMID: 26090838 DOI: 10.3171/2014.10.jns14499] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) is a therapeutic option for repeatedly hemorrhagic cavernous malformations (CMs) located in areas deemed to be high risk for resection. During the latency period of 2 or more years after SRS, recurrent hemorrhage remains a persistent risk until the obliterative process has finished. The pathological response to SRS has been studied in relatively few patients. The authors of the present study aimed to gain insight into the effect of SRS on CM and to propose possible mechanisms leading to recurrent hemorrhages following SRS. METHODS During a 13-year interval between 2001 and 2013, bleeding recurred in 9 patients with CMs that had been treated using Gamma Knife surgery at the authors' institution. Microsurgical removal was subsequently performed in 5 of these patients, who had recurrent hemorrhages between 4 months and 7 years after SRS. Specimens from 4 patients were available for analysis and used for this report. RESULTS Histopathological analysis demonstrated that vascular sclerosis develops as early as 4 months after SRS. In the samples from 2 to 7 years after SRS, sclerotic vessels were prominent, but there were also vessels with incomplete sclerosis as well as some foci of neovascularization. CONCLUSIONS Recurrent bleeding after SRS for CM could be related to incomplete sclerosis of the vessels, but neovascularization may also play a role.
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Affiliation(s)
| | - Geoffrey Murdoch
- Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ronald L Hamilton
- Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Wu H, Yu T, Wang S, Zhao J, Zhao Y. Surgical Treatment of Cerebellar Cavernous Malformations: A Single-Center Experience with 58 Cases. World Neurosurg 2015; 84:1103-11. [PMID: 26070634 DOI: 10.1016/j.wneu.2015.05.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 05/25/2015] [Accepted: 05/28/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM). METHODS We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center. RESULTS The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019). CONCLUSIONS Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function.
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Affiliation(s)
- Hongji Wu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; Department of Neurosurgery, Baoding No. 1 Central Hospital, Hebei, People's Republic of China
| | - Tao Yu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China.
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Kida Y, Hasegawa T, Iwai Y, Shuto T, Satoh M, Kondoh T, Hayashi M. Radiosurgery for symptomatic cavernous malformations: A multi-institutional retrospective study in Japan. Surg Neurol Int 2015; 6:S249-57. [PMID: 26005588 PMCID: PMC4434491 DOI: 10.4103/2152-7806.157071] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/29/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND A group study for symptomatic cavernous malformation (CM) treated with gamma knife (GK) surgery was performed. METHODS A total of 298 cases collected from 23 GK centers across Japan were included. Hemorrhage was the most common manifestation, followed by seizures and neurological deficits. Most of the lesions were located in the brainstem and basal ganglia, followed by the cerebral or cerebellar hemispheres. The CMs, which had a mean diameter of 14.8 mm, were treated using GK surgery with a mean marginal dose of 14.6 Gy. RESULTS In terms of hemorrhage-free survival (HFS), a marked dissociation was confirmed between the hemorrhage and seizure groups, while no obvious difference was noted between sexes. Superficial CMs located in cerebellum or lobar regions responded to the treatment better than deeply located CMs in the basal ganglia or brainstem. No significant difference of dose-dependent response was seen for three different ranges of marginal dose: Less than 15 Gy, between 15 and 20 Gy, and more than 20 Gy. Complications were more frequent after a marginal dose of over 15 Gy and in patients with lesions more than 15 mm in diameter. The rates of annual hemorrhage were estimated to be 7.4% during the first 2 years after radiosurgery and 2.8% thereafter. The overall hemorrhage rate after radiosurgery was 4.4%/year/patient. CONCLUSION The risk of hemorrhage is considerably reduced after GK treatment. The HFS as well as annual hemorrhage rate after GK treatment was apparently superior to that after conservative treatment for symptomatic CMs. To optimize the success of GK treatment, it is important to reduce the incidence of complications.
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Affiliation(s)
- Yoshihisa Kida
- Department of Neurosurgery, General Kamiiida Daiichi Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Toshinori Hasegawa
- Department of Neurosurgery, Komaki City Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Yoshiyasu Iwai
- Department of Neurosurgery, Osaka General Medical Center, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Takashi Shuto
- Department of Neurosurgery, Yokohama Rosai Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Manabu Satoh
- Department of Neurosurgery, Rakusai Shimizu Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Scientific Committee of Japanese Gamma Knife Society, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Scientific Committee of Japanese Gamma Knife Society, Japan
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Azimi P, Shahzadi S, Bitaraf MA, Azar M, Alikhani M, Zali A, Sadeghi S. Cavernomas: Outcomes after gamma-knife radiosurgery in Iran. Asian J Neurosurg 2015; 10:49. [PMID: 25767582 PMCID: PMC4352634 DOI: 10.4103/1793-5482.151515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients. Materials and Methods: A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records. Results: The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm3 (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. Conclusion: The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.
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Affiliation(s)
- Parisa Azimi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sohrab Shahzadi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Maziar Azar
- Department of Neurosurgery, Tehran University of Medical science, Tehran, Iran
| | - Mazdak Alikhani
- Department of Neurosurgery Iran Gamma-Knife Center, Tehran, Iran
| | - Alireza Zali
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sohrab Sadeghi
- Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Poorthuis MHF, Klijn CJM, Algra A, Rinkel GJE, Al-Shahi Salman R. Treatment of cerebral cavernous malformations: a systematic review and meta-regression analysis. J Neurol Neurosurg Psychiatry 2014; 85:1319-23. [PMID: 24667206 DOI: 10.1136/jnnp-2013-307349] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The reported effects of treating cerebral cavernous malformations (CCMs) by neurosurgical excision or stereotactic radiosurgery are imprecise and vary between studies. METHODS We searched Ovid Medline, EMBASE and The Cochrane Library for peer-reviewed publications of cohort studies describing outcomes of treating 20 or more patients with CCM with at least 80% completeness of follow-up. Two reviewers extracted data to quantify the incidence of a composite outcome (death, non-fatal intracranial haemorrhage, or new/worse persistent focal neurological deficit) after CCM treatment. We explored associations between summary measures of study characteristics and outcome using Poisson meta-regression analyses. RESULTS We included 63 cohorts, involving 3424 patients. The incidence of the composite outcome was 6.6 (95% CI 5.7 to 7.5) per 100 person-years after neurosurgical excision (median follow-up 3.3 years) and 5.4 (95% CI 4.5 to 6.4) after stereotactic radiosurgery (median follow-up 4.1 years). After neurosurgical excision the incidence of the composite outcome increased with every per cent point increase in patients with brainstem CCM (rate ratio (RR) 1.03, 95% CI 1.01 to 1.05), and decreased with each more recent study midyear (RR 0.91, 95% CI 0.85 to 0.98) and each per cent point increase in patients presenting with haemorrhage (RR 0.98, 95% CI 0.96 to 1.00). We did not find significant associations in studies of stereotactic radiosurgery. CONCLUSIONS The reported risks of CCM treatment (and the lower risks of neurosurgical excision over time, from recently bled CCMs, and for CCMs outside the brainstem) compare favourably with the risks of recurrent haemorrhage from CCM. Long-term effects, especially important for stereotactic radiosurgery, are unknown.
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Affiliation(s)
- Michiel H F Poorthuis
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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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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36
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Walcott BP, Peterson RT. Zebrafish models of cerebrovascular disease. J Cereb Blood Flow Metab 2014; 34:571-7. [PMID: 24517974 PMCID: PMC3982096 DOI: 10.1038/jcbfm.2014.27] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/27/2013] [Accepted: 01/07/2014] [Indexed: 12/18/2022]
Abstract
Perturbations in cerebral blood flow and abnormalities in blood vessel structure are the hallmarks of cerebrovascular disease. While there are many genetic and environmental factors that affect these entities through a heterogeneous group of disease processes, the ultimate final pathologic insult in humans is defined as a stroke, or damage to brain parenchyma. In the case of ischemic stroke, blood fails to reach its target destination whereas in hemorrhagic stroke, extravasation of blood occurs outside of the blood vessel lumen, resulting in direct damage to brain parenchyma. As these acute events can be neurologically devastating, if not fatal, development of novel therapeutics are urgently needed. The zebrafish (Danio rerio) is an attractive model for the study of cerebrovascular disease because of its morphological and physiological similarity to human cerebral vasculature, its ability to be genetically manipulated, and its fecundity allowing for large-scale, phenotype-based screens.
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Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Randall T Peterson
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
- Broad Institute, Cambridge, Massachusetts, USA
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Sager O, Beyzadeoglu M, Dincoglan F, Uysal B, Gamsiz H, Demiral S, Oysul K, Dirican B, Sirin S. Evaluation of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) for cerebral cavernous malformations: a 15-year single-center experience. Ann Saudi Med 2014; 34:54-8. [PMID: 24658554 PMCID: PMC6074929 DOI: 10.5144/0256-4947.2014.54] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Surgery is the principal treatment for safely accessible hemorrhagic and symptomatic cavernous malformations. Nevertheless, the role of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) in the management of high-risk, symptomatic cavernoma lesions warrants further refinement. In this study, we evaluate the use of LINAC-based SRS for cerebral cavernous malformations (CMs) and report our 15-year single-center experience. DESIGN AND SETTINGS A retrospective study from the Department of Radiation Oncology and the Department of Neurosurgery at Gulhane Military Medical Academy and Medical Faculty, Ankara from April 1998 to June 2013. PATIENTS AND METHODS Fifty-two patients (22 females and 30 males) with cerebral CM referred to our department underwent high-precision single-dose SRS using a LINAC with 6-MV photons. All patients had at least 1 bleeding episode prior to radiosurgery along with related symptoms. Median dose prescribed to the 85% to 95% isodose line encompassing the target volume was 15 Gy (range, 10-20). RESULTS Out of the total 52 patients, follow-up data were available for 47 patients (90.4%). Median age was 35 years (range, 19-63). Median follow-up time was 5.17 years (range, 0.08-9.5) after SRS. Three hemorrhages were identified in the post-SRS period. Statistically significant decrease was observed in the annual hemorrhage rate after radiosurgical treatment (pre-SRS 39% vs post-SRS 1.21, P < .0001). Overall, there were no radiosurgery-related complications resulting in mortality. CONCLUSION LINAC-based SRS may be considered as a treatment option for high-risk, symptomatic cerebral CM of selected patients with prior bleeding from lesions located at surgically inaccessible or eloquent brain areas.
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Affiliation(s)
- Omer Sager
- Dr. Omer Sager, Department of Radiation Oncology,, Gulhane Military Medical Academy and Medical Faculty,, Ankara 06018, Turkey, T: +903123044683, F: +903123044680,
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Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery 2013; 72:573-89; discussion 588-9. [PMID: 23262564 DOI: 10.1227/neu.0b013e318283c9c2] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cavernous malformations (CMs) in deep locations account for 9% to 35% of brain malformations and are surgically challenging. OBJECTIVE To study the clinical features and outcomes following surgery for deep CMs and the complication of hypertrophic olivary degeneration (HOD). METHODS Clinical records, radiological findings, operative details, and complications of 176 patients with deep CMs were reviewed retrospectively. RESULTS Of 176 patients with 179 CMs, 136 CMs were in the brainstem, 27 in the basal ganglia, and 16 in the thalamus. Cranial nerve deficits (51.1%), hemiparesis (40.9%), numbness (34.7%), and cerebellar symptoms (38.6%) presented most commonly. Hemorrhage presented in 172 patients (70 single, 102 multiple). The annual retrospective hemorrhage rate was 5.1% (assuming CMs are congenital with uniform hemorrhage risk throughout life); the rebleed rate was 31.5%/patient per year. Surgical approach depended on the proximity of the CM to the pial or ependymal surface. Postoperatively, 121 patients (68.8%) had no new neurological deficits. Follow-up occurred in 170 patients. Delayed postoperative HOD developed in 9/134 (6.7%) patients with brainstem CMs. HOD occurred predominantly following surgery for pontine CMs (9/10 patients). Three patients with HOD had palatal myoclonus, nystagmus, and oscillopsia, whereas 1 patient each had limb tremor and hemiballismus. At follow-up, 105 patients (61.8%) improved, 44 (25.9%) were unchanged, and 19 (11.2%) worsened neurologically. Good preoperative modified Rankin Score (98.2% vs 54.5%, P = .001) and single hemorrhage (89% vs 77.3%, P < .05) were predictive of good long-term outcome. CONCLUSION Symptomatic deep CMs can be resected with acceptable morbidity and outcomes. Good preoperative modified Rankin Score and single hemorrhage are predictors of good long-term outcome.
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Affiliation(s)
- Paritosh Pandey
- Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. However, there is now sufficient evidence supporting the use of SRS for the difficult cases. Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.
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Li D, Zhang J, Hao S, Tang J, Xiao X, Wu Z, Zhang L. Surgical Treatment and Long-Term Outcomes of Thalamic Cavernous Malformations. World Neurosurg 2013; 79:704-13. [DOI: 10.1016/j.wneu.2012.01.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 11/22/2011] [Accepted: 01/20/2012] [Indexed: 10/14/2022]
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Treatment of cavernoma: an evidence-based dilemma? ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 116:99-101. [PMID: 23417465 DOI: 10.1007/978-3-7091-1376-9_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Milinis K, Mohammed M, Dyer JE, Sutton PA. Cerebral cavernous malformation: a diagnostic challenge in a young patient with intracerebral haemorrhage. BMJ Case Rep 2012; 2012:bcr-2012-006215. [PMID: 22843754 DOI: 10.1136/bcr-2012-006215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 18-year-old Caucasian man presented with a sudden onset right hemiparesis. On examination, he had objective evidence of an upper motor neuron lesion affecting the right side of his body. CT scan showed a left thalamic haemorrhage. MRI, gradient echo and cerebral angiogram showed no structural lesion and the cause of the bleeding was ultimately attributed to the use of cocaine. During the subsequent 2 years the patient had two further similar episodes, with an MRI eventually demonstrating a cerebral cavernous malformation. This was excised using frameless stereotactic surgery, following which the patient made an uneventful recovery.
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Kivelev J, Koskela E, Setälä K, Niemelä M, Hernesniemi J. Long-term visual outcome after microsurgical removal of occipital lobe cavernomas. J Neurosurg 2012; 117:295-301. [PMID: 22702480 DOI: 10.3171/2012.5.jns112102] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECT Cavernomas in the occipital lobe are relatively rare. Because of the proximity to the visual cortex and incoming subcortical tracts, microsurgical removal of occipital cavernomas may be associated with a risk of visual field defects. The goal of the study was to analyze long-term outcome after operative treatment of occipital cavernomas with special emphasis on visual outcome. METHODS Of the 390 consecutive patients with cavernomas who were treated at Helsinki University Central Hospital between 1980 and 2011, 19 (5%) had occipital cavernomas. Sixteen patients (4%) were surgically treated and are included in this study. The median age was 39 years (range 3-59 years). Seven patients (56%) suffered from hemorrhage preoperatively, 5 (31%) presented with visual field deficits, 11 (69%) suffered from seizures, and 4 (25%) had multiple cavernomas. Surgery was indicated for progressive neurological deterioration. The median follow-up after surgery was 5.25 years (range 0.5-14 years). RESULTS All patients underwent thorough neuroophthalmological assessment to determine visual outcome after surgery. Visual fields were classified as normal, mild homonymous visual field loss (not disturbing the patient, driving allowed), moderate homonymous visual field loss (disturbing the patient, driving prohibited), and severe visual field loss (total homonymous hemianopia or total homonymous quadrantanopia). At the last follow-up, 4 patients (25%) had normal visual fields, 6 (38%) had a mild visual field deficit, 1 (6%) complained of moderate visual field impairment, and 5 (31%) had severe homonymous visual field loss. Cavernomas seated deeper than 2 cm from the pial surface carried a 4.4-fold risk of postoperative visual field deficit relative to superficial ones (p = 0.034). Six (55%) of the 11 patients presenting with seizures were seizure-free postoperatively. Eleven (69%) of 16 patients had no disability during the long-term follow-up. CONCLUSIONS Surgical removal of occipital cavernomas may carry a significant risk of postoperative visual field deficit, and the risk is even higher for deeper lesions. Seizure outcome after removal of these cavernomas appeared to be worse than that after removal in other supratentorial locations. This should be taken into account during preoperative planning.
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Affiliation(s)
- Juri Kivelev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Fuetsch M, El Majdoub F, Hoevels M, Müller RP, Sturm V, Maarouf M. Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas. Strahlenther Onkol 2012; 188:311-6. [PMID: 22314579 DOI: 10.1007/s00066-011-0050-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 09/15/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of deep-seated cerebral cavernous malformations (CCMs) is still controversial. Although surgery remains the treatment of choice in patients with recurrent hemorrhage, patients with CCMs located in the brainstem are in many cases not eligible for resection due to high procedure-related morbidity and mortality. We evaluated the long-term outcome of LINAC radiosurgery (LINAC-RS) for the treatment of brainstem CCMs. PATIENTS AND METHODS Between December 1992 and March 2008, 14 patients (6 men, 8 women) harboring brainstem CCMs underwent LINAC-RS. Pretreatment neuroimaging showed no associated developmental venous angiomas (DVAs) in any of our patients. Prior to treatment, all patients suffered at least from one symptomatic hemorrhage (median 1.8, range 1–3). A median follow-up of 7.1 years (range 2.0–16.8 years) could be obtained in 12 patients. We applied a median tumor surface dose of 13.9 Gy (range 11–18 Gy; median tumor volume 1.6 ml, range 0.4–4.3 ml). RESULTS Following LINAC-RS, neurological outcome improved in 4 (33.3%) and remained unchanged in 8 patients (66.7%). Rebleeding with subsequent transient neurological status deterioration occurred in 4 patients (33.3%), leading to additional surgical resection in 2 patients (16.7%). The corresponding annual hemorrhage rate was 4.8% (4/82.8 patient–years). Adverse radiation effects (ARE, defined by perilesional hyperintensity on T2-weighted MR images) were revealed in 3 patients (25%), leading to transient neurological deficits in 2 patients (16.7%). There were no procedure-related complications leading to either permanent morbidity or mortality. CONCLUSION Our results support the role of LINAC-RS as an efficient and safe treatment to significantly reduce the annual hemorrhage rate in patients suffering from brainstem CCMs not eligible to microsurgery. Compared with radiosurgery for arteriovenous malformations (AVMs), the intervention-related morbidity is higher.
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Affiliation(s)
- M Fuetsch
- Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne
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Al-Holou WN, O'Lynnger TM, Pandey AS, Gemmete JJ, Thompson BG, Muraszko KM, Garton HJL, Maher CO. Natural history and imaging prevalence of cavernous malformations in children and young adults. J Neurosurg Pediatr 2012; 9:198-205. [PMID: 22295927 DOI: 10.3171/2011.11.peds11390] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECT This study was undertaken to define the age-related prevalence of cavernous malformations (CMs) in children and young adults undergoing intracranial imaging. In addition, the authors aim to clarify the natural history of CMs in young people, especially in those with incidentally discovered lesions. METHODS To identify those patients with CMs, the authors retrospectively reviewed the electronic medical records of 14,936 consecutive patients 25 years of age or younger who had undergone brain MR imaging. In patients with a CM, clinical and imaging data were collected. Patients with untreated cavernomas who had more than 6 months of clinical and MR imaging follow-up were included in a natural history analysis. The natural history analysis included 110 CMs in 56 patients with a 3.5-year mean clinical follow-up interval (199 patient-years and 361 cavernoma-years). RESULTS In 92 patients (0.6%), 164 CMs were identified. The imaging prevalence of cavernomas increased with advancing age (p = 0.002). Multiple CMs occurred in 28 patients (30%), and 8 patients (9%) had a family history of multiple CMs. Fifty patients (54%) presented with symptoms related to the cavernoma, of whom 30 presented with hemorrhage (33%). Of the 164 cavernomas identified, 103 (63%) were considered incidental, asymptomatic lesions. Larger size was associated with acute symptomatic presentation (p = 0.0001). During the follow-up interval, 6 patients with 8 cavernomas developed 11 symptomatic hemorrhages after initial identification. Five of the patients who had a hemorrhage during the follow-up interval had initially presented with hemorrhage, while only 1 had presented incidentally. The hemorrhage rate for all patients in the natural history group was 1.6% per patient-year and 0.9% per cavernoma-year. The hemorrhage rate was 8.0% per patient-year in the symptomatic group versus 0.2% in the incidental group. Symptomatic hemorrhage after long-term follow-up was associated with initial acute presentation (p = 0.02). CONCLUSIONS The imaging prevalence of CM increases with advancing age during childhood. Patients presenting without hemorrhage have a significantly lower risk of bleeding compared with those who present with acute neurological symptoms. Comparing this series of children to prior analyses of CM natural history in adults, the authors' data do not suggest a higher bleeding risk in younger patients.
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Affiliation(s)
- Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-5338, USA
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Jay SM, Chandran H, Blackburn TPD. Gamma knife stereotactic radiosurgery for thalamic & brainstem cavernous angiomas. Br J Neurosurg 2011; 26:367-70. [PMID: 22149475 DOI: 10.3109/02688697.2011.635819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of Gamma Knife stereotactic radiosurgery (GKS) in the treatment of patients with symptomatic cavernous angiomas (CA) of the brainstem or thalamus, by comparing overall outcome to the natural history of the disease. METHODS Over 10 years a series of 16 consecutively presenting patients (M = 9, F = 7) with thalamic or brainstem CA were treated with GKS to a single lesion, specifically excluding the haemosiderin ring from the target. Within the year prior to treatment eight patients had suffered one symptomatic haemorrhage and eight had suffered more than one symptomatic haemorrhage. Mean age at treatment was 38.9 (15-55) years. Mean prescription dose 13.31 Gray (11.0 Gy-16.0 Gy). Patients were followed up radiologically and, more importantly, clinically for a mean period of 43.8 (11-101) months, median 36 months. RESULTS One patient suffered recurrent haemorrhage at 23 months post-GKS, but has not re-bled in the following 61 months. One patient died of thalamic haemorrhage from the treated lesion at 90 months. One patient was lost to follow up. There have been no other clinical episodes or radiological findings to suggest post-GKS haemorrhage in the remaining 13 patients, and no other complications were observed in the treated population. The annual haemorrhage rate within the first two years post GKS was 3.72% and the annual haemorrhage rate 2 years post GKS was 3.59% per annum. CONCLUSION With the dose regimens described, GKS is safe and effective in the treatment of thalamic and brainstem CA, as assessed by significant reduction in observed rate of re-haemorrhage over that expected from the known natural history of those CAs which have already demonstrated a tendency to haemorrhage in highly eloquent areas.
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Affiliation(s)
- S M Jay
- The London Gamma Knife Centre, St Bartholomew's Hospital, London, UK.
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Kanaan I, Jallu A, Alwatban J, Patay Z, Hessler R. Extra-axial cavernous hemangioma: two case reports. Skull Base 2011; 11:287-95. [PMID: 17167631 PMCID: PMC1656889 DOI: 10.1055/s-2001-18635] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Two patients with extra-axial cavernous hemangioma who presented with headache and oculovisual disturbances were investigated with computed tomography and magnetic resonance imaging. The lesions masqueraded as basal meningioma, but this diagnosis was not supported by magnetic resonance spectroscopy in one patient. Cerebral angiography with embolization was indicated in one patient, but embolization was not justified in the other. Both patients underwent a pterional craniotomy. The lesions were extradural and highly vascular, necessitating excessive transfusion in one patient in whom gross total resection was achieved, and precluding satisfactory removal in the other. There was no mortality. Transient ophthalmoplegia, the only complication in one patient, was due to surgical manipulation of the cavernous sinus; it resolved progressively over 3 months. Extra-axial skull base cavernous hemangiomas are distinct entities with clinical and radiological characteristics that differ from those of intraparenchymal cavernous malformations. They can mimic meningiomas or pituitary tumors. In some cases, magnetic resonance spectroscopy may narrow the differential diagnoses. Surgical resection remains the treatment of choice, facilitated by preoperative embolization to reduce intraoperative bleeding and by the application of the principles of skull base surgery. Fractionated radiotherapy is an alternative in partial or difficult resections and in high-risk and elderly patients.
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Menon G, Gopalakrishnan CV, Rao BRM, Nair S, Sudhir J, Sharma M. A single institution series of cavernomas of the brainstem. J Clin Neurosci 2011; 18:1210-4. [PMID: 21745743 DOI: 10.1016/j.jocn.2011.01.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 01/07/2011] [Indexed: 11/16/2022]
Abstract
We retrospectively analyzed a series of patients with brainstem cavernomas of the medulla, pons, or midbrain to attempt to define the natural history, indications for surgery, and outcome after surgical resection. Between 1993 and 2008, 52 patients with cavernomas of the brainstem presented to our institute and were managed either surgically or conservatively. Twenty-three patients underwent surgical excision using standard skull base approaches. Outcomes were correlated to the number of preoperative hemorrhages, location of the cavernoma, timing of surgery in relation to the hemorrhage and the preoperative neurological status. Nine patients improved after surgery, 12 deteriorated and two died. In the conservatively managed group, 15 patients had a good outcome, 11 deteriorated and one died. Multiple hemorrhages, poor preoperative neurological status and surgery during the acute phase were predictive of the surgical outcome. Excision of brainstem cavernomas should be considered in patients with symptomatic hemorrhages whose lesions approach the pial surface. Patients with minimal stable neurologic deficits without recurrent bleeds should be managed conservatively.
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Affiliation(s)
- Girish Menon
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India
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Surgical management of brainstem cavernous malformations. Neurol Sci 2011; 32:1013-28. [PMID: 21318375 DOI: 10.1007/s10072-011-0477-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
Bleeding from brainstem cavernomas may cause severe deficits due to the absence of non-eloquent nervous tissue and the presence of several ascending and descending white matter tracts and nerve nuclei. Surgical removal of these lesions presents a challenge to the most surgeons. The authors present their experience with the surgical treatment of 43 patients with brainstem cavernomas. Important aspects of microsurgical anatomy are reviewed. The surgical management, with special focus on new intraoperative technologies as well as controversies on indications and timing of surgery are presented. According to several published studies the outcome of brainstem cavernomas treated conservatively is poor. In our experience, surgical resection remains the treatment of choice if there was previous hemorrhage and the lesion reaches the surface of brainstem. These procedures should be performed by experienced neurosurgeons in referral centers employing all the currently available technology.
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