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Albalkhi I, Shafqat A, Bin-Alamer O, Mallela AN, Kuminkoski C, Labib MA, Lang MJ, Lawton MT, Morcos JJ, Couldwell WT, Abou-Al-Shaar H. Long-term functional outcomes and complications of microsurgical resection of brainstem cavernous malformations: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:252. [PMID: 37726558 DOI: 10.1007/s10143-023-02152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Brainstem cavernous malformations (CMs) encompass up to 20% of all intracranial CMs and are considered more aggressive than cerebral CMs because of their high annual bleeding rates. Microsurgical resection remains the primary treatment modality for CMs, but long-term functional outcomes and complications are heterogenous in the literature. The authors performed a systematic review on brainstem CMs in 4 databases: PubMed, EMBASE, Cochrane library, and Google Scholar. We included studies that reported on the long-term functional outcomes and complications of brainstem CMs microsurgical resection. A meta-analysis was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search yielded 4781 results, of which 19 studies met our inclusion criteria. Microsurgery was performed on 940 patients (mean age 35 years, 46.9% females). Most of the brainstem CMs were located in the pons (n = 475). The pooled proportions of improved, stable, and worsened functional outcomes after microsurgical resection of brainstem CMs were 56.7% (95% CI 48.4-64.6), 28.6% (95% CI 22.4-35.7), and 12.6% (95% CI 9.6-16.2), respectively. CMs located in the medulla were significantly (p = 0.003) associated with a higher proportion of improved outcome compared with those in the pons and midbrain. Complete resection was achieved in 93.3% (95% CI 89.8-95.7). The immediate postoperative complication rate was 37.2% (95% CI 29.3-45.9), with new-onset cranial nerve deficit being the most common complication. The permanent morbidity rate was 17.3% (95% CI 10.5-27.1), with a low mortality rate of 1% from the compiled study population during a mean follow-up of 58 months. Our analysis indicates that microsurgical resection of brainstem CMs can result in favorable long-term functional outcomes with transient complications in the majority of patients. Complete microsurgical resection of the CM is associated with a lower incidence of CM hemorrhage and the morbidity related to it.
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Affiliation(s)
- Ibrahem Albalkhi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chloe Kuminkoski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohamed A Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jacques J Morcos
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Tatagiba M, Lepski G, Kullmann M, Krischek B, Danz S, Bornemann A, Klein J, Fahrig A, Velnar T, Feigl GC. The Brainstem Cavernoma Case Series: A Formula for Surgery and Surgical Technique. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1601. [PMID: 37763720 PMCID: PMC10537097 DOI: 10.3390/medicina59091601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cavernous malformations (CM) are vascular malformations with low blood flow. The removal of brainstem CMs (BS) is associated with high surgical morbidity, and there is no general consensus on when to treat deep-seated BS CMs. The aim of this study is to compare the surgical outcomes of a series of deep-seated BS CMs with the surgical outcomes of a series of superficially located BS CMs operated on at the Department of Neurosurgery, College of Tuebingen, Germany. Materials and Methods: A retrospective evaluation was performed using patient charts, surgical video recordings, and outpatient examinations. Factors were identified in which surgical intervention was performed in cases of BS CMs. Preoperative radiological examinations included MRI and diffusion tensor imaging (DTI). For deep-seated BS CMs, a voxel-based 3D neuronavigation system and electrophysiological mapping of the brainstem surface were used. Results: A total of 34 consecutive patients with primary superficial (n = 20/58.8%) and deep-seated (n = 14/41.2%) brainstem cavernomas (BS CM) were enrolled in this comparative study. Complete removal was achieved in 31 patients (91.2%). Deep-seated BS CMs: The mean diameter was 14.7 mm (range: 8.3 to 27.7 mm). All but one of these lesions were completely removed. The median follow-up time was 5.8 years. Two patients (5.9%) developed new neurologic deficits after surgery. Superficial BS CMs: The median diameter was 14.9 mm (range: 7.2 to 27.3 mm). All but two of the superficial BS CMs could be completely removed. New permanent neurologic deficits were observed in two patients (5.9%) after surgery. The median follow-up time in this group was 3.6 years. Conclusions: The treatment of BS CMs remains complex. However, the results of this study demonstrate that with less invasive posterior fossa approaches, brainstem mapping, and neuronavigation combined with the use of a blunt "spinal cord" dissection technique, deep-seated BS CMs can be completely removed in selected cases, with good functional outcomes comparable to those of superficial BS CM.
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Affiliation(s)
- Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Guilherme Lepski
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Marcel Kullmann
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Boris Krischek
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Soeren Danz
- Department of Neuroradiology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Antje Bornemann
- Department of Neuropathology, University of Tuebingen Medical Center, 72074 Tübingen, Germany
| | - Jan Klein
- Institute for Medical Image Computing, Fraunhofer MEVIS, 28359 Bremen, Germany
| | - Antje Fahrig
- Department of Radiotherapy and Radiooncology, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
| | - Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Guenther C. Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, 72074 Tübingen, Germany
- Department of Neurosurgery, General Hospital Klinikum Bamberg, 96049 Bamberg, Germany
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Kikuta KI, Isozaki M, Higashino Y, Kodera T, Arishima H, Matsuda K, Yamauchi T, Yamada S, Akazawa A, Kidoguchi M, Umeda H, Tsukinowa Y, Hagiwara R. Functional Outcomes of Microsurgical Resection for Cavernous Malformations of the Brainstem. Adv Tech Stand Neurosurg 2022; 44:121-132. [PMID: 35107676 DOI: 10.1007/978-3-030-87649-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Long-term functional outcomes of microsurgical resection for cavernous malformations of the brainstem (CMB) have been largely unknown. Favorable outcomes after CMB surgery might be related to the achievement of complete resection and mRS at 1 month after the surgery. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms tended to improve after surgery.We evaluated 25 consecutive patients with CMB surgically treated at our center between 2006 and 2021. The subjects included 11 men and 14 women, with ages ranging from 13 to 61 years (mean ± SD = 37 ± 12 years). Modified Rankin Scale (mRS) scores and neurological symptoms of the patients were evaluated before surgery, 1 month after surgery, and at the final follow-up at the outpatient clinic. The mean number of previous hemorrhages was 7 ± 1.0 and the mean lesion size was 21 ± 8 mm. The mRS scores on admission and at the final follow-up were 2.9 points and 1.7 points, respectively. The mRS scores at the final follow-up were significantly improved compared to those on admission. There was no statistical difference between the preoperative mRS and mRS at 1 month after the operation. Multivariable analysis indicated that mRS scores at 1 month after surgery were the most significant predictive factors for favorable outcomes. Complete resection was achieved in 24 of 33 operations. Incomplete resection was significantly related to the frequency of subsequent recurrent hemorrhage and high mRS scores at the final follow-up. Preoperative sensory, cerebellar, trigeminal nerve, and lower cranial nerve symptoms improved significantly after surgery.
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Affiliation(s)
- Ken-Ichiro Kikuta
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.
| | - Makoto Isozaki
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshifumi Higashino
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Toshiaki Kodera
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hidetaka Arishima
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ken Matsuda
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Takahiro Yamauchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Shinsuke Yamada
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ayumi Akazawa
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masamune Kidoguchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hideto Umeda
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yu Tsukinowa
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ryota Hagiwara
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Chen B, Göricke S, Wrede K, Jabbarli R, Wälchli T, Jägersberg M, Sure U, Dammann P. Reliable? The Value of Early Postoperative Magnetic Resonance Imaging after Cerebral Cavernous Malformation Surgery. World Neurosurg 2017; 103:138-144. [PMID: 28391022 DOI: 10.1016/j.wneu.2017.03.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cerebral cavernous malformations (CCM) can cause intracerebral hemorrhage. The lesions themselves are frequently associated with perifocal hemosiderin deposits caused by repetitive microhemorrhages. Main indications for a surgical treatment are recurrent symptomatic hemorrhages or cavernoma-related epilepsy. After surgical resection, follow-up magnetic resonance imaging (MRI) is usually performed to confirm 1) the complete resection of the CCM and, especially in cases of cavernoma-related epilepsy, 2) the complete resection of the hemosiderin deposits. METHODS This prospective study evaluates the value of early postoperative MRI (within 72 hours) regarding the detection of CCM or hemosiderin remnants compared with a standard 3-6 months postoperative MRI control in 61 CCM cases. RESULTS Sensitivity of early postoperative MRI for CCM remnant detection was 66.67% (95% confidence interval [CI], 9.43%-99.16%), specificity was 76.74% (95% CI, 61.37%-88.24%), positive predictive value was 16.67% (95% CI, 2.09%-48.41%), and negative predictive value was 97.06% (95% CI, 84.67%-99.93%). Because of the high number of patients who could not be evaluated because of imaging artifacts, sensitivity and specificity analysis was not performed for early postoperative MRI using T2*/susceptibility-weighted imaging to assess hemosiderin remnants. Sensitivity of early postoperative MRI for hemosiderin remnant detection using T2-weighted sequences was 85.71% (95% CI, 63.66%-96.95%), specificity was 66.67% (95% CI, 44.68%-84.37%), positive predictive value was 69.23% (95% CI, 55.45%-80.27%), and negative predictive value was 84.21% (95% CI, 64.31%-94.04%). CONCLUSIONS Our data suggest that early postoperative MRI after CCM surgery is often hampered by imaging artifacts creating false-positive results and therefore ineligible for a resection control. However, reliability of a negative result on early postoperative T2-weighted MRI is relatively high regarding both CCM and hemosiderin remnants.
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Affiliation(s)
- Bixia Chen
- Department of Neurosurgery, University Hospital Essen, Essen, Germany.
| | - Sophia Göricke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Karsten Wrede
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Thomas Wälchli
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Max Jägersberg
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital Essen, Essen, Germany; Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
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Lee SJ, Hwang SC, Im SB, Kim BT. Surgical Resection of Non-Glial Tumors in the Motor Cortex. Brain Tumor Res Treat 2016; 4:70-76. [PMID: 27867915 PMCID: PMC5114195 DOI: 10.14791/btrt.2016.4.2.70] [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: 05/11/2016] [Revised: 06/28/2016] [Accepted: 07/12/2016] [Indexed: 11/20/2022] Open
Abstract
Background Direct surgery to resect tumors in the motor cortex could improve neurological symptoms or cause novel motor weakness. The present study describes the neurological outcomes of patients after the surgical resection of non-glial tumors in the primary motor cortex. Methods The present study included 25 patients who had pathologically confirmed non-glial tumors in the motor cortex for which they underwent surgery. Tumor location was verified using anatomical landmarks on preoperative magnetic resonance imaging scans. All surgeries involved a craniotomy and tumor resection, especially use of the sulcal dissecting approach for intra-axial tumors. Results Of the 25 patients, 10 exhibited metastasis, 13 had a meningioma, and 2 had a cavernous malformation. Motor weakness and seizures were the most common symptoms, while 3 patients experienced only a headache. The tumor size was less than 20 mm in 4 patients, 20–40 mm in 14, and greater than 40 mm in seven. Of the 25 patients, 13 exhibited motor weakness prior to the operation, but most of these symptoms (76.9%) improved following surgery. On the other hand, eight patients experienced seizures prior to the surgery, and in three of these patients (37.5%), the seizures were not controlled after the surgery. In terms of surgical complications, a postoperative hematoma developed in one of the meningioma patients, and the patient's hemiparesis was aggravated. Conclusion The present findings show that careful and meticulous resection of non-glial tumors in the motor cortex can improve preoperative neurological signs, but it cannot completely control seizure activity.
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Affiliation(s)
- Seong-Jong Lee
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Matsushima K, Yagmurlu K, Kohno M, Rhoton AL. Anatomy and approaches along the cerebellar-brainstem fissures. J Neurosurg 2015; 124:248-63. [PMID: 26274986 DOI: 10.3171/2015.2.jns142707] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fissure dissection is routinely used in the supratentorial region to access deeply situated pathology while minimizing division of neural tissue. Use of fissure dissection is also practical in the posterior fossa. In this study, the microsurgical anatomy of the 3 cerebellar-brainstem fissures (cerebellomesencephalic, cerebellopontine, and cerebellomedullary) and the various procedures exposing these fissures in brainstem surgery were examined. METHODS Seven cadaveric heads were examined with a microsurgical technique and 3 with fiber dissection to clarify the anatomy of the cerebellar-brainstem and adjacent cerebellar fissures, in which the major vessels and neural structures are located. Several approaches directed along the cerebellar surfaces and fissures, including the supracerebellar infratentorial, occipital transtentorial, retrosigmoid, and midline suboccipital approaches, were examined. The 3 heads examined using fiber dissection defined the anatomy of the cerebellar peduncles coursing in the depths of these fissures. RESULTS Dissections directed along the cerebellar-brainstem and cerebellar fissures provided access to the posterior and posterolateral midbrain and upper pons, lateral pons, floor and lateral wall of the fourth ventricle, and dorsal and lateral medulla. CONCLUSIONS Opening the cerebellar-brainstem and adjacent cerebellar fissures provided access to the brainstem surface hidden by the cerebellum, while minimizing division of neural tissue. Most of the major cerebellar arteries, veins, and vital neural structures are located in or near these fissures and can be accessed through them.
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Affiliation(s)
- Ken Matsushima
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and.,Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Albert L Rhoton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and
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Qiao N, Ma Z, Song J, Wang Y, Shou X, Zhang X, Shen M, Qiu H, Ye Z, He W, Li S, Fu C, Zhao Y. A systematic review and meta-analysis of surgeries performed for treating deep-seated cerebral cavernous malformations. Br J Neurosurg 2015; 29:493-9. [PMID: 25813882 DOI: 10.3109/02688697.2015.1023773] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The clinical benefit of surgery for treatment of deep-seated cerebral cavernous malformations (CCMs) is still a matter of debate. Although the surgical removal of CCMs is widely accepted, the benefits of reducing the rate of haemorrhage must be balanced against the risk of peri-operative morbidity. Here, we provide a systematic review and meta-analysis of the clinical benefits of surgery for treating deeply localised CCMs. METHODS A comprehensive search of PubMed and Embase was conducted to identify relevant studies. The rate and a 95% confidence interval (CI) were used to measure the risk of haemorrhage and adverse outcomes. RESULTS A total of 34 cohort studies reporting surgeries on CCMs were included in our analysis. Overall, the average post-surgical haemorrhage rate was 1.0% (95% CI: 0.7-1.4%). Nine per cent (95% CI: 6.9-11.3%) of the patients developed adverse events at follow-up following the surgical resection of deep-seated CCMs. The percentage of transient neural defects following surgical resection was 34.6% (95% CI: 29.4-39.9%). The proportions of transient focal neurological defect before and after the year 2006 were 44.9% (95% CI: 34.1-55.8%) and 30.3% (95% CI: 25.1-35.9%), respectively. CONCLUSIONS Our meta-analysis demonstrates post-surgical haemorrhage rate and complications related to surgeries on deep-seated CCMs. The post-surgical haemorrhage rate was low with a relatively high rate of post-surgical complications.
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Affiliation(s)
- Nidan Qiao
- a Department of Neurosurgery , HuaShan Hospital, Shanghai Medical College, Fudan University , Shanghai , China
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Li D, Hao SY, Tang J, Xiao XR, Jia GJ, Wu Z, Zhang LW, Zhang JT. Surgical management of pediatric brainstem cavernous malformations. J Neurosurg Pediatr 2014; 13:484-502. [PMID: 24679081 DOI: 10.3171/2014.2.peds13536] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to evaluate surgical outcomes of pediatric brainstem cavernous malformations (CMs) and identify the risk factors associated with postoperative full recovery and rebleeding. METHODS The clinical charts and radiographs from a series of 52 pediatric patients (37 male and 15 female; mean age 12.2 years; range 1-17 years) who underwent surgery for brainstem CMs between 1996 and 2011 were reviewed. Follow-up evaluation measures were obtained retrospectively. Neurological function was evaluated using the modified Rankin Scale (mRS) score. RESULTS The lesion locations among the 52 patients included the midbrain (n = 7, 13.5%), pons (n = 38, 73.1%), and medulla (n = 7, 13.5%). The mean duration of symptoms was 18.5 months, and the preoperative annual hemorrhage and rebleeding rates were 12.3% and 32.5% per patient-year, respectively. The mean lesion size was 2.1 cm. Gross-total resection without surgery-related death was achieved in 49 patients (94.2%). Immediate postoperative reduced neurological function was observed in 17 patients (32.7%). Surgical morbidities developed in 25 patients (48.1%) and remained in 11 patients (21.2%) after 7.9 years of follow-up. The mean mRS scores at admission, discharge after surgery, 3 and 6 months postsurgery, and recent evaluation were 2.0, 2.3, 2.0, 1.5, and 1.0, respectively. The postoperative mRS scores at 6 months (p < 0.001) and on recent evaluation (p < 0.001) were significantly lower than those at admission. Postoperative rebleeding occurred in 2 patients, and the postoperative annual rebleeding rate was 0.5% per patient-year. By the most recent evaluation, 10 patients (19.2%) had achieved full recovery and all patients were either improved (n = 32, 61.5%) or unchanged (n = 20, 38.5%). The adverse predictors for full recovery included age ≥ 12 years (HR 0.230, p = 0.021), ≥ 2 preoperative hemorrhages (HR 0.124, p = 0.048), and poor preoperative status (HR 0.197, p = 0.040). An HR < 1 predicted poor complete recoveries. The single risk factor predicting postoperative rebleeding was incomplete resection (χ2 = 4.340, p = 0.037). CONCLUSIONS Fair outcomes for pediatric brainstem CMs could be obtained through surgery, but only a few patients achieved full recovery. Thus, to minimize surgical morbidity, surgical planning must be tailored to individual patients in all cases in which an operation is warranted. Complete resection must be attempted to reduce the risk of postoperative rebleeding. The predictors associated with complete postoperative recovery were referential for determining treatment.
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Affiliation(s)
- Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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Sanborn MR, Kramarz MJ, Storm PB, Adappa ND, Palmer JN, Lee JYK. Endoscopic, endonasal, transclival resection of a pontine cavernoma: case report. Neurosurgery 2012; 71:198-203. [PMID: 22572676 DOI: 10.1227/neu.0b013e318259e323] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Hemorrhagic, symptomatic cavernous malformations in the brainstem are difficult to access. Conventional approaches such as the transpetrosal approach often require significant brain retraction. We present the successful purely endoscopic, endonasal, transclival resection of a symptomatic cavernoma located in the ventromedial pons. CLINICAL PRESENTATION A 17-year-old male patient presented with acute onset of headache, facial numbness, and tingling. Magnetic resonance imaging demonstrated an enhancing lesion in the pons consistent with a cavernous malformation. Over the course of the next 3 weeks, the patient had 2 additional episodes of acutely worsening neurological deficits that left him with left-sided hemiparesis, a right sixth nerve palsy, and dysphagia. A purely endoscopic, endonasal, transclival approach was used to resect the cavernoma. Postoperatively, he had a transient worsening of his left-side motor function and restricted horizontal gaze, but at the last follow-up, his hemiparesis had improved and his magnetic resonance imaging demonstrated a radiographic cure. He developed a cerebrospinal fluid (CSF) leak despite prophylactic lumbar CSF drainage for 2 days and the use of bilateral vascularized nasoseptal flaps. The CSF leak was repaired with CSF diversion and a second surgical procedure; at the last follow-up, he had no recurrence of the leak. CONCLUSION An endoscopic, endonasal, transclival approach is a novel and effective approach to cavernous malformations presenting to the ventral surface of the pons. Recently developed techniques for closure and repair of the skull base defect have minimized but have not eliminated the risk of CSF leak in these procedures.
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Affiliation(s)
- Matthew R Sanborn
- Department of Neurosurgery, Perelman School of Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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de Aguiar PHP, Zicarelli CAM, Isolan G, Antunes A, Aires R, Georgeto SM, Tahara A, Haddad F. Brainstem cavernomas: a surgical challenge. EINSTEIN-SAO PAULO 2012; 10:67-73. [PMID: 23045829 DOI: 10.1590/s1679-45082012000100014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. METHODS From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. RESULTS The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. CONCLUSIONS Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.
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Asaad WF, Walcott BP, Nahed BV, Ogilvy CS. Operative management of brainstem cavernous malformations. Neurosurg Focus 2010; 29:E10. [PMID: 20809751 DOI: 10.3171/2010.6.focus10134] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Brainstem cavernous malformations (CMs) are complex lesions associated with hemorrhage and neurological deficit. In this review, the authors describe the anatomical nuances relating to the operative techniques for these challenging lesions. The resection of brainstem CMs in properly selected patients has been demonstrated to reduce the risk of rehemorrhage and can be achieved relatively safely in experienced hands.
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Affiliation(s)
- Wael F Asaad
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Ichinose T, Goto T, Morisako H, Takami T, Ohata K. Microroll retractor for surgical resection of brainstem cavernomas. World Neurosurg 2010; 73:520-2. [PMID: 20920936 DOI: 10.1016/j.wneu.2010.06.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 05/27/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Safe and complete surgical resection of brainstem cavernoma is difficult without injury surrounding normal structures because the lesions are deep and intra-axial. In this article, the authors describe the "microroll retractor" technique for brainstem cavernoma surgery. METHODS The microroll retractor is made of expanded polytetrafluoroethylene sheet. The sheet is cut in several sizes of square piece and transformed into a tubular shape. We insert this roll retractor via minimal brain incision and keep surgical corridor without usual spatulas during lesionectomy. RESULTS This technique was adopted for 7 patients with brainstem cavernomas. In all patients, we achieved total excision; improvement was recorded in 6 patients, and no change was recorded in 1 patient. CONCLUSIONS The microroll retractor is extremely simple but provides enough surgical corridors for safe total resection of brainstem cavernomas.
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Affiliation(s)
- Tsutomu Ichinose
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Dammann P, Barth M, Zhu Y, Maderwald S, Schlamann M, Ladd ME, Sure U. Susceptibility weighted magnetic resonance imaging of cerebral cavernous malformations: prospects, drawbacks, and first experience at ultra–high field strength (7-Tesla) magnetic resonance imaging. Neurosurg Focus 2010; 29:E5. [DOI: 10.3171/2010.6.focus10130] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
High-resolution susceptibility weighted MR imaging at high field strength provides excellent depiction of venous structures, blood products, and iron deposits, making it a promising complementary imaging modality for cerebral cavernous malformations (CCMs). Although already introduced in 1997 and being constantly improved, susceptibility weighted imaging is not yet routine in clinical neuroimaging protocols for CCMs. In this article, the authors review the recent literature dealing with clinical and scientific susceptibility weighted imaging of CCMs to summarize its prospects and drawbacks and provide their first experience with its use in ultra–high field (7-T) MR imaging.
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Affiliation(s)
- Philipp Dammann
- 1Erwin L. Hahn Institute for Magnetic Resonance Imaging; Departments of
- 2Neurosurgery and
| | - Markus Barth
- 1Erwin L. Hahn Institute for Magnetic Resonance Imaging; Departments of
- 3Radboud University Nijmegen, Donders Institute for Cognitive Neuroimaging, Nijmegen, The Netherlands
| | | | - Stefan Maderwald
- 1Erwin L. Hahn Institute for Magnetic Resonance Imaging; Departments of
- 4Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany; and
| | - Marc Schlamann
- 4Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany; and
| | - Mark E. Ladd
- 1Erwin L. Hahn Institute for Magnetic Resonance Imaging; Departments of
- 4Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany; and
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Huang APH, Chen JS, Yang CC, Wang KC, Yang SH, Lai DM, Tu YK. Brain stem cavernous malformations. J Clin Neurosci 2009; 17:74-9. [PMID: 20005720 DOI: 10.1016/j.jocn.2009.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
Abstract
We retrospectively reviewed the clinical experience of 30 patients with brain stem cavernous malformations (BSCM) treated operatively and non-operatively at our hospital between 1983 and 2005 to elucidate the natural history of BSCM and the factors that affect surgical outcome. Inpatient charts, imaging studies, operative records, and follow-up results were evaluated. The average follow up was 48.5 months. Twenty-two patients (73.3%) received surgical extirpation and of these 86.4% improved or stabilized and 13.6% deteriorated with permanent or severe morbidity. There was no mortality. Size, preoperative status, and surgical timing were factors related to surgical outcome. In the non-operative group, 50% of the patients were the same or better, 25% deteriorated, and 25% died. With appropriate patient selection, resection of BSCM can be achieved with acceptable morbidity compared with the ominous natural history of these lesions.
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Affiliation(s)
- Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chung Shan South Road, Taipei 100, Taiwan
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15
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Bhardwaj RD, Auguste KI, Kulkarni AV, Dirks PB, Drake JM, Rutka JT. Management of pediatric brainstem cavernous malformations: experience over 20 years at the hospital for sick children. J Neurosurg Pediatr 2009; 4:458-64. [PMID: 19877780 DOI: 10.3171/2009.6.peds0923] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Because of their location and biological behavior, brainstem cavernous malformations (CMs) pose a formidable clinical challenge to the neurosurgeon. The optimal management of these lesions requires considerable neurosurgical judgment. Accordingly, the authors reviewed their experience with the management of pediatric brainstem CMs at the Hospital for Sick Children. METHODS The authors performed a retrospective chart review of pediatric patients who had received diagnoses of a brainstem CM at the Hospital for Sick Children over the past 20 years. RESULTS Twenty patients were diagnosed with brainstem CMs. The mean age at diagnosis was 10.1 +/- 5.4 years, and the patients included 13 boys and 7 girls. The mean maximal diameter of the CM was 14.3 +/- 11.2 mm. The lesions were evenly distributed on the right and left sides of the brainstem with 4 midbrain, 13 pontine, and 3 medullary lesions. Seven patients underwent surgery for the management of their CMs, with a mean age at presentation of 5.2 years, and a mean CM size of 21.0 mm. Of note from the surgical group, 2 patients had a family history of CMs, 2 lesions were medullary, the CM reached a pial surface in 6 of 7 patients, and 6 of 7 lesions were located on the right side. The mean age at presentation among the 13 patients in the nonsurgical group was 12.7 years, and the mean CM size was 10.6 mm. Seven of these patients had a prior history of radiation for tumor, and only 3 had lesions that reached a pial surface. CONCLUSIONS The management of brainstem CMs in children is influenced by multiple factors. The majority of patients received conservative management and tended to be asymptomatic with smaller lesions. Patients with larger lesions and direct pial contact, in whom symptoms arose at a younger age were more likely to undergo surgical management. A history of familial CM was also a predictor for receiving surgical treatment. No patients with a prior history of radiation therapy underwent surgery for CMs. The presence of multiple lesions seemed to have no impact on the type of management chosen. Patients who underwent surgery did suffer morbidity related to the procedure, and tended to improve clinically over time. Conservative management was associated with new deficits arising in children, some of which improved with time. Consideration of many clinical and radiological parameters is thus prudent when managing the care of children with brainstem CMs.
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Affiliation(s)
- Ratan D Bhardwaj
- Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, The University of Toronto, Toronto, Ontario, Canada
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Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. ACTA ACUST UNITED AC 2009; 72 Suppl 2:S3-9; discussion S9-10. [PMID: 19665186 DOI: 10.1016/j.surneu.2009.05.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 05/27/2009] [Indexed: 01/01/2023]
Abstract
BACKGROUND The contemporary neurosurgeon is often confronted by cavernous malformations. Those located in the brainstem are particularly challenging METHODS This article reviews published series on the natural history and surgical outcomes of these lesions and discusses the surgical approaches used at our institution for their resection. RESULTS Despite their challenging location in the brainstem, appropriately selected lesions can be resected surgically with acceptable rates of morbidity and mortality. CONCLUSIONS Our institutional philosophy on the surgical treatment of brainstem cavernous malformations reflects the substantial surgical experience of the senior author.
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Affiliation(s)
- Mark Garrett
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Gross BA, Batjer HH, Awad IA, Bendok BR. BRAINSTEM CAVERNOUS MALFORMATIONS. Neurosurgery 2009; 64:E805-18; discussion E818. [DOI: 10.1227/01.neu.0000343668.44288.18] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bradley A. Gross
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Issam A. Awad
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Bernard R. Bendok
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
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Nataf F, Roux FX, Devaux B, Page P, Turak B, Dezamis E, Abi Lahoud G. Cavernomes du tronc cérébral: l'expérience chirurgicale du centre hospitalier Sainte-Anne. Neurochirurgie 2007; 53:192-201. [PMID: 17499815 DOI: 10.1016/j.neuchi.2007.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 03/10/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE No standard treatment for brainstem cavernoma has been established because of the lack of sufficient data about the natural history of these lesions in a highly functional location with potential difficult surgical accessibility. METHODS We present a series of 82 brainstem cavernomas managed at the Sainte-Anne Hospital. Surgery was undertaken for 25 with stereotactic biopsy for 9 and direct surgery for 19 (3 after biopsy). RESULTS Surgical outcome was good or fair for 17 patients. Two patients worsened and one died. Biopsy results were disappointing with high morbidity (4 patients with 2 permanent deficits). Histological diagnostic was possible for all biopsies. CONCLUSION In light of these results, an active surgical attitude could be proposed for cavernomas in an accessible locations which have produced at least one previous hemorrhage. Stereotactic biopsies for suspect brainstem cavernoma must be avoided.
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Affiliation(s)
- F Nataf
- Service de neurochirurgie, centre hospitalier Sainte-Anne, 1 rue Cabanis, 75014 Paris, France.
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Bruneau M, Bijlenga P, Reverdin A, Rilliet B, Regli L, Villemure JG, Porchet F, de Tribolet N. Early surgery for brainstem cavernomas. Acta Neurochir (Wien) 2006; 148:405-14. [PMID: 16311840 DOI: 10.1007/s00701-005-0671-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Accepted: 09/22/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome. METHOD We retrospectively reviewed 22 patients harboring a BSC, who underwent 23 procedures. FINDINGS Surgery was carried out during the early stage after the last haemorrhage, with a mean delay of 21.6 days (range 4-90 days). Sixteen procedures were performed after a first bleeding event while seven after multiple bleedings. Complete resection was achieved in 19 patients (86.4%). Early after surgery, 12 patients (52.2%) improved neurologically, 5 (21.7%) were stable and 6 (26.1%) worsened. New postoperative deficits were noted after 9 procedures (39.1%). Statistically significant factors for postoperative aggravation were: late surgery (P = 0.046) and multiple bleedings (P = 0.043). No patient operated on within the first 19 days after bleeding did worsen (n = 11), as opposed to 6 out of 12 who did when operated on later. After a mean follow-up of 44.9 months, 20 patients (90.9%) were improved, 1 patient (4.6%) was worse and 1 patient was lost to follow-up (4.6%), after reoperation for rebleeding of a previously completely resected cavernoma. Late morbidity was reduced to 8.6%. The mean Glasgow Outcome Scale (GOS) at the end of the follow-up period was 4.24, compared to a mean preoperative GOS of 3.22 (P<0.001). Complete neurological recovery of motor deficits, sensory disturbances, cranial nerves (CNs), internuclear ophtalmoplegia and cerebellar dysfunction were respectively 41.7%, 38.5%, 52.6%, 60.0% and 58.3%. Among the most affected CNs: CN 3, CN 5 and CN 7 were more prone to completely recover, respectively in 60.0%, 70.0% and 69.2%. CONCLUSIONS Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome. Early surgery and single bleeding were associated with better surgical results.
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Affiliation(s)
- M Bruneau
- Department of Neurosurgery, University Hospital, Geneva, Switzerland
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