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Velz J, Özkaratufan S, Krayenbühl N, Beccaria K, Akeret K, Attieh C, Ghannam B, Guida L, Benichi S, Bozinov O, Puget S, Blauwblomme T, Regli L. Pediatric brainstem cavernous malformations: 2-center experience in 40 children. J Neurosurg Pediatr 2022; 29:612-623. [PMID: 35303707 DOI: 10.3171/2022.1.peds21538] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCMs) are relatively uncommon, low-flow vascular lesions in children. Given the paucity of data, guidelines regarding the clinical management of BSCMs in children are lacking and the surgical indication is most commonly based on an individual surgeon's judgment and experience. The goal in this study was to evaluate the clinical behavior of BSCMs in childhood and the long-term outcome in children managed conservatively and surgically. METHODS This was an observational, retrospective study including all children with BSCMs who were followed at 2 institutions between 2008 and 2020. RESULTS The study population consisted of 40 children (27 boys, 67.5%) with a mean age of 11.4 years. Twenty-three children (57.5%) were managed conservatively, whereas 17 children (42.5%) underwent resection of BSCMs. An aggressive clinical course was observed in 13 children (32.5%), who experienced multiple hemorrhages with a progressive pattern of neurological decline. Multiple BSCMs were observed in 8 patients, of whom 3 patients presented with a complex of multiple tightly attached BSCMs and posed a significant therapeutic challenge. The overall long-term outcome was favorable (modified Rankin Scale [mRS] scores 0-2) in 36 patients (90%), whereas an unfavorable outcome (mRS scores 3 and 4) was seen in 4 children (10%). An mRS score of 5 or 6 was not observed. The mean (± SD) follow-up was 88.0 (± 92.6) months. CONCLUSIONS The clinical course of BSCMs in children is highly variable, with benign lesions on the one hand and highly aggressive lesions with repetitive hemorrhages on the other. Given the greater life expectancy and the known higher functional recovery in children, surgical treatment should be considered early in young patients presenting with surgically accessible lesions and an aggressive clinical course, and it should be performed in a high-volume center.
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Affiliation(s)
- Julia Velz
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Sena Özkaratufan
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Niklaus Krayenbühl
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
- 3Division of Pediatric Neurosurgery, University Children's Hospital Zurich, Switzerland
| | - Kevin Beccaria
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Kevin Akeret
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
| | - Christian Attieh
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Boulos Ghannam
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
| | - Lelio Guida
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Sandro Benichi
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Oliver Bozinov
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 6Department of Neurosurgery, Kantonsspital St. Gallen, Switzerland; and
| | - Stephanie Puget
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 7Department of Neurosurgery, Hôpital Pierre Zobda Quitman, CHU de Fort de France, Université des Antilles, Fort de France, Martinique
| | - Thomas Blauwblomme
- 4Department of Pediatric Neurosurgery, APHP, Hôpital Necker, Paris, France
- 5Université de Paris, France
| | - Luca Regli
- 1Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Switzerland
- 2University of Zurich, Switzerland
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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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Yang Y, Velz J, Neidert MC, Lang W, Regli L, Bozinov O. The BSCM score: a guideline for surgical decision-making for brainstem cavernous malformations. Neurosurg Rev 2021; 45:1579-1587. [PMID: 34713352 PMCID: PMC8976795 DOI: 10.1007/s10143-021-01679-y] [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: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
Microsurgical resection of brainstem cavernous malformations (BSCMs) can be performed today with acceptable morbidity and mortality. However, in this highly eloquent location, the indication for surgery remains challenging. We aimed to elaborate a score system that may help clinicians with their choice of treatment in patients with BSCMs in this study. A single-center series of 88 consecutive BSCMs patients with 272 follow-up visits were included in this study. Univariable and multivariable generalized estimating equations (GEE) were constructed to identify the association of variables with treatment decisions. A score scale assigned points for variables that significantly contributed to surgical decision-making. Surgical treatment was recommended in 37 instances, while conservative treatment was proposed in 235 instances. The mean follow-up duration was 50.4 months, and the mean age at decision-making was 45.9 years. The mean BSCMs size was 14.3 ml. In the multivariable GEE model, patient age, lesion size, hemorrhagic event(s), mRS, and axial location were identified as significant factors for determining treatment options. With this proposed score scale (grades 0–XII), non-surgery was the first option at grades 0–III. The crossover point between surgery and non-surgery recommendations lay between grades V and VI while surgical treatment was found in favor at grades VII–X. In conclusion, the proposed BSCM operating score is a clinician-friendly tool, which may help neurosurgeons decide on the treatment for patients with BSCMs.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland. .,Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
| | - Wei Lang
- Department of Geriatric Medicine, University Hospital Zurich, City Hospital Waid Zurich, Tiechestrasse 99, CH-8037, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Ramistrasse 100, CH-8091, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St. Gallen, Switzerland
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Yang Y, Velz J, Neidert MC, Stienen MN, Regli L, Bozinov O. Natural History of Brainstem Cavernous Malformations: On the Variation in Hemorrhage Rates. World Neurosurg 2021; 157:e342-e350. [PMID: 34656794 DOI: 10.1016/j.wneu.2021.10.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hemorrhage rates of conservatively managed brainstem cavernous malformations (BSCMs) vary widely in the literature. We aimed to elucidate the reason for the variation and to add the results of our experience of BSCMs management over the past decade. METHODS We performed a review of consecutive patients with BSCMs referred to our department in the period 2006-2018. A hemorrhagic event was defined as a radiographically verified intralesional and extralesional hemorrhage. Both retrospective and prospective hemorrhage rates were calculated based on the patient age in years, counted either from birth or from the time of initial presentation until the last contact (or until surgical resection). In addition, we retrieved and reviewed publications with a clear definition of hemorrhagic event and a detailed description of BSCM hemorrhage rate. RESULTS In total, 118 patients with BSCMs were reviewed, and 78 patients (mean age on admission 45.9 years) were included in the final analysis. The retrospective and prospective hemorrhage rates were 1.9% (95% confidence interval 1.6%-2.3%) per year and 11.9% (95% confidence interval 7.5%-17.8%), respectively. The retrospective hemorrhage rate in the literature review ranged from 1.9% to 6.8% per year with a median value of 3.8%, whereas the prospective hemorrhage rate ranged between 4.1% and 21.5%, with a median value of 10.2%. CONCLUSIONS The reported hemorrhage rates are calculated in 2 different ways. In our patient cohort, both the retrospective and prospective hemorrhage rates were in accordance with those in the literature. The long-term hemorrhage rate lies between the prospective and retrospective rate.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland; Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland.
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher St. Gallen, Switzerland
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Velz J, Neidert MC, Yang Y, Akeret K, Nakaji P, Regli L, Bozinov O. Mortality in Patients with Brainstem Cavernous Malformations. Cerebrovasc Dis 2021; 50:574-580. [PMID: 34134124 DOI: 10.1159/000516909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Brainstem cavernous malformations (BSCM)-associated mortality has been reported up to 20% in patients managed conservatively, whereas postoperative mortality rates range from 0 to 1.9%. Our aim was to analyze the actual risk and causes of BSCM-associated mortality in patients managed conservatively and surgically based on our own patient cohort and a systematic literature review. METHODS Observational, retrospective single-center study encompassing all patients with BSCM that presented to our institution between 2006 and 2018. In addition, a systematic review was performed on all studies encompassing patients with BSCM managed conservatively and surgically. RESULTS Of 118 patients, 54 were treated conservatively (961.0 person years follow-up in total). No BSCM-associated mortality was observed in our conservatively as well as surgically managed patient cohort. Our systematic literature review and analysis revealed an overall BSCM-associated mortality rate of 2.3% (95% CI: 1.6-3.3) in 22 studies comprising 1,251 patients managed conservatively and of 1.3% (95% CI: 0.9-1.7) in 99 studies comprising 3,275 patients with BSCM treated surgically. CONCLUSION The BSCM-associated mortality rate in patients managed conservatively is almost as low as in patients treated surgically and much lower than in frequently cited reports, most probably due to the good selection nowadays in regard to surgery.
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Affiliation(s)
- Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Marian Christoph Neidert
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Yang Yang
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Peter Nakaji
- Department of Neurosurgery at Banner, University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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