Abstract
In this study, we aimed to introduce a technical note and to explore the efficacy of endoscopic surgery combined with diffusion tensor imaging (DTI) navigation for supratentorial deep cerebral cavernous malformations (CCM). A prospectively maintained database of CCM patients was reviewed to identify all CCM patients treated by endoscopic surgery. The sagittal T1-weighted anatomical magnetic resonance imaging (MRI) and DTI were acquired before surgery. Endoscopic surgery was planned and performed based on preoperative DTI images and intraoperative DTI navigation. All patients were followed up more than 6 months. Motor function deficit and modified Rankin scale (mRS) scores were documented on follow-up. A final mRS score of 0–2 was considered a good outcome, and a final mRS score >2 was considered a poor outcome. Second DTI and 3DT1 were performed at 3 months after surgery. We tracked the ipsilateral corticospinal tract (CST) on pre- and postoperative DTI images. The overall mean FA values and the number of fibers of tracked CST were compared on pre- and postoperative DTI images. Risk factors associated with motor deficits and poor outcomes were analyzed. Seven patients with deep CCM and treated by endoscopic surgery were enrolled in this study. The mean value of preoperative mRS was 1.5 ± 0.98, but that score recovered to 0.86 ± 1.22 3 months later. The mRS scores were improved significantly according to statistical analysis (p = 0.012). According to the Spearman non-parametric test, only the fiber number of ipsilateral CST on postoperative DTI was significantly associated with muscle strength 6 months after surgery (p = 0.032). Compared with preoperative CST characteristics on DTI, the change of FA value (p = 0.289) and fiber number (p = 0.289) of ipsilateral CST on postoperative DTI was not significant It meant that the CST was protected during endoscopic surgery. Endoscopic surgery based on DTI navigation might be an effective method to protect fiber tracts in supratentorial deep CCM patients and improve long-term outcomes. However, more studies and cases are needed to confirm our findings.
Highlights
Deep cerebral cavernous malformations (CCM) account for 9–35% of intracranial CCMs, including corona radiata, paraventricular, intraventricular, insula, basal ganglia, and brainstem CCMs [1]
Three male and four female patients with deep CCM and treated by endoscopic surgery were enrolled in this study, and their mean age at presentation was 49.0 ± 6.58 years old (Table 2)
Two of the lesions were located at the corona radiata level and three at the basal ganglia level
Summary
Deep cerebral cavernous malformations (CCM) account for 9–35% of intracranial CCMs, including corona radiata, paraventricular, intraventricular, insula, basal ganglia, and brainstem CCMs [1]. Surgical resection is often performed under a microscope with the help of a plate retractor. Accurate positioning and sparing adjacent eloquent fibers are the key points for the safe resection of deep CCMs. With the rapid advancement of imaging software and transparent tube sheath, endoscopic surgery has gradually become an effective and well-accepted method for treating deep intracranial hemorrhage (ICH) and supratentorial parenchymal tumors [3, 4]. Combining the accuracy of intraoperative neuronavigation and minimally invasive endoscopic surgery, it may be an effective way to remove supratentorial deep CCMs. In this study, we introduced the technical notes and reported the outcomes of endoscopic surgery patients, to determine the efficacy of endoscopic surgery combined with diffusion tensor imaging (DTI) navigation for supratentorial deep cavernous malformations
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