Brainstem Hemorrhage Research Articles

Deep brain stimulation of the ventralis intermedius nucleus of the thalamus and posterior subthalamic area for Holmes’ tremor secondary to brainstem hemorrhage: A case report

Holmes’ tremor is a rare but severely disabling movement disorder characterized by a combination of resting, action, and intention tremor. Because Holmes’ tremor is usually resistant to pharmacotherapy, surgical treatment is required for symptom control in most cases. We report the case of a 56-year-old man who was diagnosed with Holmes’ tremor and treated with stimulation of the ventralis intermedius nucleus of the thalamus and posterior subthalamic area. Deep brain stimulation alleviated the patient’s tremor over a 3-year follow-up period.

Surgical Treatment for Primary Brainstem Hemorrhage to Improve Postoperative Functional Outcomes

It remains controversial whether primary brainstem hemorrhage (PBH) should be managed conservatively or treated promptly by surgical evacuation of the hematoma. In the present study, we discuss 5 cases of PBH that were treated surgically and the ability of surgical management to improve postoperative functional outcomes. The 4 patients with pontine and medullary hemorrhage underwent surgery via the lateral or midline suboccipital and trans-rhomboid fossa approach in the half-sitting position. The patient with a midbrain hemorrhage underwent surgery via the subtemporal approach in the supine lateral position. We analyzed the postoperative functional outcomes 1 week after surgery and the modified Rankin scale scores 6 months after discharge. Three patients with disturbance of consciousness experienced improvement in their level of consciousness. Four patients with hemiparesis improved in motor function. Oculomotor nerve function improved in 2 of 3 cases. Facial nerve function improved in 2 of 2 cases. Spontaneous respiration improved in 1 patient. The postoperative modified Rankin scale scores improved in all 5 cases. Because of the good results with these 5 patients with PBH, this surgical strategy could be encouraged with exclusion criteria for early initiation of rehabilitation strategies. We hope to increase our number of patients to accumulate further evidence.

A Rare Complication of Chronic Subdural Hematoma Evacuation: Brain Stem Hemorrhage: A Case Report

Abstract Chronic subdural hematoma (CSDH), which commonly affects the elderly, is one of the most frequent, but also benign neurosurgical pathologies. Burr hole drainage is the standard surgical modality for evacuation of a CSDH. This technique is known to be safe, with low morbidity and mortality rates. However, postoperative complications have occasionally been reported. We report the case of a 70-year-old man who presented a fatal brain stem hemorrhage after burr-hole drainage for unilateral chronic subdural hematoma. Asymmetrical and rapid decompression were thought to be leading to vascular disruption or sudden increase in cerebral blood flow, was probably responsible for the secondary brain stem bleeding. Therefore, a slow rate of evacuation of chronic subdural hematomas, as well as rigorous postoperative reanimation, are recommended in order to prevent serious complications.

Radiation-Induced Cavernous Malformations After Single-Fraction Meningioma Radiosurgery.

Stereotactic radiosurgery (SRS) is a commonly performed procedure for patients with intracranial meningiomas. To describe the clinical features of patients with radiation-induced cavernous malformations (RICM) after single-fraction meningioma SRS. Retrospective study of patients having single-fraction SRS for intracranial meningioma at our center from 1990 through 2009, and 1 patient who had single-fraction SRS elsewhere. Patients were excluded if they refused research authorization (n=7), had a World Health Organization Grade II or III meningioma (n=65), had a genetic predisposition for tumor development (n=52), had prior or concurrent radiation therapy (n=49), or had less than 2 yr of magnetic resonance imaging follow-up after SRS (n=77). The median follow-up of the remaining 426 patients was 7.9 yr (range, 2-24.9). Three RICM (0.7%) were identified at 2, 10, and 21 yr after SRS. Two patients were asymptomatic, whereas 1 patient had a brainstem hemorrhage causing facial weakness and numbness. The risk of developing an RICM after SRS was 0.2% at 5 yr and 0.9% at 15 yr. All patients were observed and remained stable without additional bleeding in follow-up of 7, 12.8, and 2 yr, respectively. A fourth patient developed progressive neurological dysfunction starting 7 yr after SRS at another center and was treated for several years with bevacizumab without improvement. Surgical resection was performed 11.5 yr after SRS and histologic examination was consistent with an RICM. The risk of RICM after single-fraction SRS for intracranial meningiomas is very low, but the latency period noted until their detection emphasizes the need for extended imaging follow-up after SRS of benign lesions.

Predictors of mortality and recurrent stroke within five years of intracerebral hemorrhage

Objective There are limited studies exploring prognosis after intracerebral hemorrhage (ICH) in Chinese populations. Thus, we evaluated the risk factors and predictors of mortality and recurrent stroke in a large clinical cohort at a single institution.Methods We analysed consecutive cases of spontaneous ICH at admission to our hospital from September 2010 to December 2016. Independent predictors of mortality at one month and five year follow-up, as well as stroke recurrence were analysed.Results A total of 1187 cases were included (33.5% women). The one month case fatality rate was 12.5%, and the five year mortality rate was 22.2%. In the multivariate analysis, diabetes was an independent predictor of one month case fatality, and older age (≥65 years) was an independent predictor of five year mortality. Brain stem hemorrhage and intraventricular hemorrhage were independent predictors of both short- and long-term mortality. The overall recurrence rate was 32.5% among one month survivors.Conclusion Predictors of recurrent stroke were older females, hypertension, diabetes, and brain stem hemorrhage. These findings may help to determine specific treatment strategies and improve quality of health care for such patients.

Rat Brainstem Hemorrhage Model: Key Points to Success in Modeling

A successful animal brainstem hemorrhage model can be used to study pathophysiology and molecular mechanisms of neurologic deterioration or recovery and therapeutic interventions after the brainstem hemorrhage. Herein, we provide a reproducible and reliable model for rat brainstem hemorrhage and summarize our key points to success in modeling. Twenty-four adult male Sprague-Dawley rats were divided into 3 groups and were injected with 30, 40, and 60 μL autologous blood into the right pontine basal tegmentum after being sedated. The initial model was evaluated with neurobehavior testing, autopsy, and histopathology. The modeling conditions were modified in Group IV rats, and 20 more rats were used to check the reproducibility and reliability of the modified model. Finally, magnetic resonance imaging (MRI) was used to confirm the brainstem hemorrhage. Only 6 rats had significant pontine hemorrhage in initial 3 groups on autopsy. Whereas after the modification, all Group IV rats had serious pontine hemorrhage, and modified conditions model had a 90% success rate. MRI confirmed a stable hematoma in the right basal tegmental pons with oval shape 24 hours after of blood injection. Histopathologically, there was significant perihematomal swelling, migration of inflammatory cells and structural changes in neuronal shape and contents. An ideal and repeatable rat brainstem hemorrhage model by injecting autologous blood stereotactically was created, and it mimics the natural onset of brainstem hemorrhage. This brainstem hemorrhage model shows promise that providing a better way for neurology researchers to investigate pathophysiologic procedure of brainstem intracranial hemorrhage and further explore the treatment.

Spontaneous Intracerebral Hemorrhage in a Plateau Area: A Study Based on the Tibetan Population

To reveal the characteristics of spontaneous intracerebral hemorrhage (sICH) in a plateau area based on the Tibetan population. Data of Tibetan and Han patients (control group) with sICH treated at our center from January 2013 to April 2017 were retrospectively reviewed. A total of 122 Tibetan and 927 Han patients were included. Compared with Han patients, Tibetan patients were older (54.7 ± 11.2 vs. 50.9 ± 18.3 years, P=0.027), exhibited higher male-to-female ratios (73.8% vs. 55.0%, P < 0.001), were more overweight (22.1% vs. 13.1%, P= 0.007) had more smokers (36.9% vs. 20.5%, P<0.001), had a higher concentration of hemoglobin (163.7 ± 17.6 vs. 134.8 ± 20.2 g/L, P<0.001), and included a higher number of patients with hypertension (83.6% vs. 60.5%, P<0.001), diabetes mellitus (19.2% vs. 9.3%, P= 0.002), and prior hemorrhagic stroke (9.0% vs. 2.0%, P < 0.001). Tibetan patients also experienced more brainstem hemorrhage (11.5% vs. 5.1%, P= 0.039) in the infratentorial region and had a higher risk of in-hospital complications resulting from hematoma enlargement (20.5% vs. 10.4%, P= 0.002) and cerebral infarction (59.0% vs. 9.7%, P< 0.001). During a 6-month follow-up period, they had higher rates of unfavorable outcomes and case mortality (P < 0.05). A multivariable analysis adjusted for confounding factors revealed that the Tibetan race was positively associated with unfavorable clinical outcomes in sICH patients (P < 0.05). Tibetan sICH patients from the plateau area presented unique characteristics in their baseline measurements, incidence of comorbidities, hematoma location, risk of in-hospital complications, and clinical outcomes compared with Han patients. The Tibetan race was positively associated with unfavorable 6-month outcomes in ICH patients.

Neutrophil and Platelet to Lymphocyte Ratios in Associating with Blood Glucose Admission Predict the Functional Outcomes of Patients with Primary Brainstem Hemorrhage

Because of a lack of markers for predicting prognosis and an underlying mechanism, patients with primary brainstem hemorrhage (PBH) are currently treated with multiple strategies, but most of them have poor outcomes in a comparison with patients with supratentorial intracranial hemorrhage. Recently, it has been reported that the neutrophil-to-lymphocyte ratio (NLR) represents a novel composite inflammatory marker to predict the prognosis of patients with intracranial hemorrhage, a majority of whom have supratentorial hemorrhage. In this report, we aim to assess the potential predictive value of NLR in patients with PBH. In addition, other available laboratory parameters, including platelet-to-lymphocyte ratio (PLR), and admission blood glucose level (ABG), will be also investigated as markers for prognosis in patients with PBH. This study retrospectively enrolled 225 patients with acute PBH who were admitted West China Hospital from January 2012 to December 2016. ABG and absolute numbers of neutrophils, lymphocytes, white blood cells, and platelets were extracted from electronic medical records. ABG, NLR, and PLR were calculated and further assessed using multivariable logistic regression analysis for understanding the associations of treatment outcomes. The comparison of predictive power of independent predictors was evaluated using receiver operating characteristic. Of 225 inpatients, NLR (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.62, P < 0.01), PLR (OR, 1.43; 95% CI, 1.11-2.36; P= 0.013), and ABG (OR, 6.57; 95% CI, 2.78-15.52; P<0.01) were independently associated with 90-day status in 112 patients with unfavorable outcomes. All 3 parameters also correlated with admission Glasgow Coma Scale score (r=-0.244, P<0.001; r=-0.292, P < 0.001; r=-0.661, P < 0.01) and absolute neutrophil counts (r= 0.645, P < 0.001; r= 0.347, P < 0.001; r=0.695, P < 0.01). Meanwhile, NLR exhibits a comparable predictive power by comparing with PLR (area under the curve [AUC], 0.694; 95% CI, 0.626-0.764; P < 0.001; versus AUC, 0.662; 95% CI, 0.596-0.724; P < 0.001). In addition, ABG shows a positive predictive value (AUC, 0.784; 95% CI, 0.725-0.832; P < 0.001). The best independent predictive cutoff points were 6.65, 59.3, and 7.81 mmol/L for NLR, PLR, and ABG, respectively. Nevertheless, a combination of 3 parameters shows the best predictive ability (AUC, 0.835; 95% CI, 0.781-0.883; P < 0.001). NLR, PLR, and ABG can be used to independently predict 90-day functional outcome in patients after PBH. When combined, they have better predictive power in identifying PBH patients with a poor prognosis. To our knowledge, this study is the first to reveal the associations between NLR, PLR, and hyperglycemia and the functional outcomes of patient with PBH. In associating with previously studies on hemorrhage site, our results provide a good opportunity to elucidate the underlying mechanisms of PBH.

Abstract WP343: EEG Seizures in Patients With Intraparenchymal Hemorrhage Reveals a Significant Role for Subcortical Hemorrhages in Epileptogenicity

Introduction: Patients with intra-parenchymal (IPH) have seizures detected on continuous EEG (cEEG) monitoring, but data that define seizure risk in IPH patients is limited. Methods: A retrospective chart review of 110 consecutive patients that had ICH on CT or MRI imaging and cEEG monitoring from January 2013 to December 2014 was completed. Patients with isolated cerebellar or brainstem hemorrhages were excluded. Primary aim was to examine the incidence of seizures and abnormal EEG patterns in patients with IPH, particularly those patients with deep IPH. Secondary aim was to examine time from EEG placement to first seizure Results: Median age was 73 [IQR 83-60]. 25 (22.73%) of the 110 patients had an abnormal EEG, defined as the presence of periodic lateralized epileptiform discharges (PLEDS) and/or seizures. 40 (36.36%) had subcortical white matter or thalamic or basal ganglia IPH +/- IVH. 5 (12.5%) of these 40 patients had EEG seizures. 66 (60%) patients had cortical IPH +/- IVH. 11 (16.67%) of these 66 patients had seizures. [OR=0.71, CI=0.23 to 2.23, p=0.56]. 4 patients had both deep and cortical IPH and were excluded. A total of 18 (16.36% of the 110) patients had EEG seizures. Of these 18 patients, 5 (27.78%) patients had deep IPH +/- IVH, defined as subcortical white matter, thalamic or basal ganglia IPH. 11 (61.11%) of the 18 had cortical hemorrhage +/- IVH. 2 (10.5 %) additional patients had both cortical and deep IPH. Additionally, of the 25 patients with abnormal EEG, 7(28%) patients had deep IPH +/- IVH 15(60%) of the 25 patients had cortical hemorrhage +/- IVH. Thus 17.5% of patients with deep IPH and 22.7% of patients with cortical IPH had abnormal cEEG.[OR=0.55, CI=0.20 to 1.48, p=0.23]. Average time for EEG placement from admission was 6 hours and 9 minutes. Average time from EEG placement to first seizure was 7 hours and 4 minutes. Discussion: Subcortical IPH is common and can lead to seizure risk. Our results show that a significant portion of the patients with IPH and seizures on cEEG monitoring had subcortical hemorrhages. They accounted for 28% of cases with seizures and abnormal EEG as well as for 13% of all the patients with subcortical ICHs. This data suggests that patients with supratentorial IPH should be evaluated for subclinical seizures.

Traumatic Isolated Brain Stem Hematoma: A Case Report Presenting with Hemiparesis

Isolated brain stem hemorrhages are rare but have a high mortality rate after blunt head trauma. 56-year-old male admitted to the emergency room with weakness on the right side of his body, one day after the blunt head trauma. Right hemiparesis which is near to plegia lower extremity motor weakness level was higher than upper extremity was found on his neurological examination. T2-weighted images and susceptibility weighted images SWI of the magnetic resonance revealed heterogenous hyperintense lesion with hemorrhage at the left side of the pons. The patient was managed with conservative treatment; at three-month follow-up, near total recovery was observed on his neurological examination. As a conclusion, it could be said that brain stem contusion with hemorrhage could be kept in mind in patient with hemiparesis if the neurological deficit of the patient cannot be explained by supratentorial or spinal cord lesions

Explore the method of observing dynamic changes in microcirculation of rabbit's duodenal mucosal villi with a red color coordinate following brainstem hemorrhage

Explore the method of observing dynamic changes in microcirculation of rabbit's duodenal mucosal villi with a red color coordinate following brainstem hemorrhage

Clinical analysis of extended endoscopic endonasal approach for craniopharyngioma treatment

Objective To evaluate the efficacy and safety of extended endoscopic endonasal approach for resection of craniopharyngiomas. Methods The clinical data of 32 patients with craniopharyngiomas undergoing extended endoscopic endonasal surgery at Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University between November 2014 and May 2016 were analyzed retrospectively. The visual improvement, extent of resection and surgical complications were evaluated. Results The gross total resection (GTR) rate was 69% (22/32), near-total resection (> 95% of tumor removed) was 25% (8/32), and subtotal resection (≥ 80% of tumor removed) was 6% (2/32). Overall, 28 patients presented with visual impairment. In 86% (24 patients) of them, visions were improved or even recovered to normal following surgery. Worsening of the anterior pituitary function was reported in 53% (17 patients) of all, and there were 12 new cases (48% of 25) of postoperative diabetes insipidus. Thirteen (41%) patients had hyposmia and 3 (9%) patients developed severe hypomnesia after surgery. CSF leakage and secondary meningitis occurred in 1 (3%) patient postoperatively. One (3%) patient had brainstem hemorrhage after surgery. The follow-up lasted 4-22 months. No tumor recurrence was identified by MRI examination, and one patient died. Conclusions The extended endoscopic endonasal approach for craniopharyngiomas seems generally effective and safe with high GTR rate, which however could also cause damage of hypothalamic-pituitary axis. Thus, continuous attention should be paid to preservation of the endocrine function during surgical management of craniopharyngioma. Key words: Craniopharyngioma; Neuroendoscopy; Neurosurgical procedures; Treatment outcome; Extended endonasal approach

Brainstem arteriovenous malformations: lesion characteristics and treatment outcomes.

OBJECTIVE Brainstem arteriovenous malformations (AVMs) are rare lesions that are difficult to diagnose and treat. They are often more aggressive in their behavior when compared with their supratentorial counterparts. The consequence of a brainstem hemorrhage is often devastating, and many patients are in poor neurological status at presentation. The authors examine the factors associated with angiographically confirmed cure and those affecting management outcomes for these complex lesions. METHODS This was a retrospective analysis of data gathered from the prospectively maintained Stanford AVM database. Lesions were grouped based on their location in the brainstem (medulla, pons, or midbrain) and the quadrant they occupied. Angiographic cure was dichotomized as completely obliterated or not, and functional outcome was dichotomized as either independent or not independent at last follow-up. RESULTS Over a 23-year period, 39 lesions were treated. Of these, 3 were located in the medulla, 14 in the pons, and 22 in the midbrain. At presentation, 92% of the patients had hemorrhage, and only 43.6% were functionally independent. Surgery resulted in the best radiographic cure rates, with a morbidity rate of 12.5%. In all, 53% of patients either improved or remained stable after surgery. Absence of residual nidus and female sex correlated with better outcomes. CONCLUSIONS Brainstem AVMs usually present with hemorrhage. Surgery offers the best chance of cure, either in isolation or in combination with other modalities as appropriate.

Фатальный некротизирующий гранулематозный васкулит после бариатрической операции и двусторонней маммопластики

The aim of case presentation. To present a typical case of systemic autoimmune disease related to extremely aggressive medical alterations of the immune status which were carried out not only for life-saving indications, but for cosmetic reasons as well. Summary. The patient (32-year-old female) had a history of persistent irregular febrile fever for two years, renal disease (tubulointerstitial nephritis with papillary necrosis), hemorrhagic vasculitis-like skin involvement and mediastinal lymphadenopathy. Patient underwent multiple investigations aimed for ruling out infectious causes of the disease that yielded negative result, repetitive courses of antibiotics provided transient positive effect at onset of disease. Five years before the origin of symptoms patients underwent sleeve gastrectomy with biliopancreatic shunting for obesity (body weight - 130 kg, BMI - 43.4 kg/m2), cholecystectomy and appendectomy. After that within a year patient lost 55 kg of body weight and developed severe symptoms of malabsorption. In 1.5 years after the fever onset bilateral mammaplasty with silicone implants was carried following which the fever became constant. At transthoracic biopsy of mediastinal lymph nodes demonstrated the pattern of Wegener-type ANCA-negative necrotizing granulomatous vasculitis of small arteries (PCR for mycobacteria and acid fast stain were negative). Despite provided corticosteroid and cyclophosphan treatment, the disease progressed (focal affection of the lungs) and the patient died of brain stem hemorrhage. Autopsy revealed the signs of vasculitis with involvement of the brain, skin, mediastinal lymphnodes, lungs, as well as the signs of chronic inflammation, atrophy of breast gland lobules, embolization of the focal lymphatics by the implant substance, ulceronecrotic enteritis of defunctioning bowel, severe liver steatosis with the chronic vitamin deficiency. Conclusion. The relation of atypical necrotizing vasculitis with yet undescribed clinical presentation with previous bariatric surgery and long-standing malabsorption is highly probable; application of silicone implants with adjuvant-associated immune response were additional resolving factors. Incomplete effect of immunosuppressive therapy indicates the dominant role of autoinflammation in the course of disease. Selection of patients for bariatric and cosmetic surgery should be more careful and involve estimation of the general and immune status of the body.

Mapping the Internal Anatomy of the Lateral Brainstem: Anatomical Study with Application to Far Lateral Approaches to Intrinsic Brainstem Tumors.

IntroductionIntramedullary brainstem tumors present a special challenge to the neurosurgeon. Unfortunately, there is no ideal part of the brainstem to incise for approaches to such pathology. Therefore, the present study was performed to identify what incisions on the lateral brainstem would result in the least amount of damage to eloquent tracts and nuclei. Case illustrations are also discussed.Materials and methodsEight human brainstems were evaluated. Based on dissections and the use of standard atlases of brainstem anatomy, the most important deeper brainstem structures were mapped to the surface of the lateral brainstem.ResultsWith these data, we defined superior acute and inferior obtuse corridors for surgical entrance into the lateral brainstem that would minimize injury to deeper tracts and nuclei, the damage to which would result in significant morbidity.ConclusionsTo our knowledge, a superficial map of the lateral brainstem for identifying deeper lying and clinically significant nuclei and tracts has not previously been available. Such data might decrease patient morbidity following biopsy or tumor removal or aspiration of brainstem hemorrhage. Additionally, this information can be coupled with the previous literature on approaches into the fourth ventricular floor for more complex, multidimensional lesions.

Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes &gt; 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p&lt;0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes &gt; 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

Application of T-Wave Alternans in Evaluation of Prognosis in Patients with Intracerebral Hemorrhage

Objective: To explore the application value of electrocardiograph (ECG) T-wave Alternans (TWA) anomaly in acute stage of intracerebral hemorrhage patients. Methods: We choose 1175 intracerebral hemorrhage patients whose conventional 12-lead ECG has TWA in our hospital from January 2011 to December 2015, 751 patients without TWA in the same period as the control group, compared the volume of intracerebral hemorrhage, bleeding site and mortality between the 2 groups. Results: In TWA group, 247 cases died, 361 cases with massive intracerebral hemorrhage, 298 cases with brain stem hemorrhage; in TWA negative group (control group), 41 cases died, 93 cases with massive brain hemorrhage, 64 cases with brain stem hemorrhage. There are statistical differences between two groups (P < 0.05). Multi factor Logistic regression analysis showed that massive intracerebral hemorrhage, brain stem hemorrhage, Glasgow score and TWA were the independent factors in the prognosis of intracerebral hemorrhage (P < 0.05). Conclusion: The occurrence of TWA is significantly related to the volume of bleeding, the bleeding site and mortality, and can be used as an important parameter in the prognosis of intracerebral hemorrhage.

Gamma Knife Radiosurgery for Hemorrhagic Brainstem Cavernomas.

To assess treatment results of gamma knife radiosurgery (GKRS) for hemorrhagic brainstem cavernous malformations (BSCMs). A retrospective review of patients with hemorrhagic BSCMs, who were treated at the Acıbadem Kozyatagi Hospital GKRS unit from May 2007 to October 2015 was performed. In total, 82 patients were identified. All patients had experienced at least one hemorrhagic event (range 1-3), and all of them presented with radiological evidence of hemorrhage. The median target volume was 0.3 ml, and the median marginal radiation dose was 12 Gy. The mean durations before and after surgery were 25.5 (range 1-204) months, and 50.3 (range 13-113) months, respectively. Pre-treatment hemorrhage rates were calculated from the date of first hemorrhage to the date of radiosurgery. There were 97 bleeds over 174.4 patient-years during the observation period, with an annual hemorrhage rate of 55.7%. If the first bleed is excluded, the annual hemorrhage rate was 8.6%. Only three patients demonstrated re-bleeding, which occurred at 3, 12 and 79 months after radiosurgery. Over a total follow up time of 344 patient-years the annual re-bleeding rate was therefore 0.87%, indicating that the risk of BSCM hemorrhage was significantly decreased by radiosurgery. GKRS was a safe and effective treatment for symptomatic low volume BSCMs when a low marginal dose is used. A randomized controlled trial is needed that compares GKRS to observation if we want to establish the true efficacy of this treatment.

Gamma Knife Radiosurgery of Brainstem Cavernous Malformations

Background/Aims: Our study aimed to evaluate the efficiency and morbidity of Gamma Knife radiosurgery (GKS) in the treatment of hemorrhagic brainstem cavernous malformations (CMs). Methods: We included in this study all patients who underwent GKS for the treatment of a hemorrhagic brainstem CM(s) in our institution between January 2007 and December 2012. The GKS was privileged when the surgical procedure was evaluated as very risky. The mean dose of radiation was 14.8 Gy, and the mean target volume was 0.282 cm³. All patients participated in a scheduled clinical follow-up. The posttreatment MRI was performed after 6 months and after 1 year, and then all patients had an annual MRI follow-up. Results: There were 19 patients with a mean age of 36.7 years. The mean follow-up period was 51.2 months. The annual hemorrhage rate (AHR) was 27.31% before GKS, 2.46% during the first 2 years following the GKS, and 2.46% after the first 2 years following the GKS. The decrease in AHR after GKS was significant (p < 0.001). Conclusion: GKS should be suggested when the surgical procedure harbors a high risk of neurological morbidity in patients with brainstem CM. Compared to prior literature results, a lower dose than applied in this study could be discussed.

Leaving no man's land.

Brenda had had a brainstem hemorrhage and survived. But 4 months later, and after 2 weeks of rigorous rehabilitation, this 55-year-old woman was not improving.