Brainstem Cavernous Malformations Research Articles

Transcondylar Approach for Resection of Medullary Cavernous Malformation: 2-Dimensional Operative Video.

Cavernous malformations located within the brainstem present with a high rate of neurological symptoms and carry a more aggressive course in both pediatric and adult populations.1,2 Cavernomas within the medulla are the rarest form, representing only 5% of all brainstem lesions.3 Repeated hemorrhage of brainstem cavernomas is associated with significant and cumulative neurological deficits and thus requires treatment.4 Microsurgical resection has become the optimal mode of treatment with the aim of resecting the live malformation and not merely the multiaged, organized hematoma.4 This is best achieved by approaching the cavernoma at the location where it projects to the surface and entering the lesion through a safe brainstem anatomic zone. For ventrally located lesions in the medulla, a transcondylar skull base approach provides a direct trajectory to the entry zone through a short surgical distance without the need to manipulate or retract neurovascular structures.5-8 Neuronavigation and intraoperative neurophysiological monitoring of somatosensory evoked potential, motor, and lower cranial nerves are adjuncts to increase patient safety. Radiosurgery for the treatment of brainstem cavernous malformations has been proposed; however, it demonstrates high risk and variable and often poor response rates.9 We present a surgical video demonstrating the transcondylar approach and resection of a medullary cavernoma in a 54-yr-old woman who has had multiple known prior hemorrhages and presented with a new onset of facial numbness and weakness, ataxia, and left body sensory loss. The patient consented to surgery and to photograph publication. Images at 1:28, 1:43 (left), 2:02 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997,5 with permission. Images at 1:43 (right) from Arnautovic et al,8 with permission from JNSPG.

Follow the Venous Path to the Hidden Lesion: A Technical Trick in Brainstem Cavernous Malformation Surgery

Deep-seated brainstem cavernous malformations (BSCMs) pose a particular challenge for brainstem entry intraoperatively and their treatment can require comprehensive application of neuronavigation, electrophysiological brainstem mapping and monitoring, and full knowledge of safe brainstem entry zones. In the present report, we have introduced a supplementary technical trick for localizing a hidden tiny lesion inside the brainstem when a developmental venous anomaly (DVA) is present on the brainstem surface. A retrospective analysis of a 74-case cohort treated surgically from January 2011 to December 2019 was conducted. We identified 11 patients (14.9%) whose deep-seated BSCMs were exposed and removed following a brainstem surface DVA path as a supplementary technical trick. We have presented 2 typical cases to illustrate the operative nuances. Of the 11 patients, 5 were male and 6 were female. Their average age was 38.0 ± 14.0 years (range, 15-62 years). Most BSCMs were located in the pons (n= 5; 45.5%), followed by the pontomesencephalic area (n= 3; 27.3%), midbrain (n= 2; 18.2%), and medulla oblongata (n= 1; 9.1%). All BSCMs were successfully located and completely removed. In 5 cases, the DVA was impaired after lesion removal (45.5%). However, no aggravated postoperative brainstem edema occurred in any of the 11 patients. After 3.6 ± 2.0 years of follow-up (2 patients were lost to follow-up; follow-up rate, 81.8%), no rebleeding was found, and the modified Rankin scale score of the patients had improved from 2.7 ± 1.1 preoperatively to 1.7 ± 0.9 at follow-up (P= 0.031). The presented method could help surgeons trace deep-seated BSCMs with minimal brainstem parenchyma impairment, avoiding unnecessary aggressive exploration.

A comparative analysis of the modified Rankin Scale, Karnofsky Performance Status and Kurtzke expanded disability status scale in the perioperative management of patients with brainstem cavernous malformations

BackgroundThe neurological conditions of brainstem cerebral cavernous malformation (BCM) patients are usually ascertained using Karnofsky Performance Status (KPS) or the modified Rankin scale (mRS). However, these scales do not reflect slight changes in brainstem function, because neither KPS nor mRS includes brainstem symptoms such as worsening of swallowing or diplopia. The main problem when managing the BCM patients is that we can neither systematically record neurological changes nor conduct clinical outcome investigations of BCM due to the lack of an adequately detailed assessment system. PurposeWe investigated the usefulness of the Kurtzke expanded disability status scale (EDSS), which is already in widespread clinical use for multiple sclerosis because it provides certainty in evaluating brainstem symptoms. MethodsWe retrospectively analyzed neurological transitions in surgical BCM cases using the modified Rankin scale (mRS), Karnofsky performance status (KPS), and EDSS. We compared each neurological score transition, and determined which scale allows the most accurate recording of neurological changes in patients. ResultsWe proposed lesion removal for patients who showed both neurological deterioration and lesion enlargement caused by re-bleeding, and the surgery was accepted by 10 patients. EDSS allowed us to assess patient status more accurately than KPS or mRS particularly during the perioperative period. In the statistical analysis, only EDSS differed significantly during the period between the initial proposal of surgery and the immediate preoperative period. ConclusionOur results suggest EDSS to be superior for managing BCM patients, as compared to KPS and mRS. Thus, EDSS may serve as an alternative scale for assessing BCM patients.

Mortality in Patients with Brainstem Cavernous Malformations

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.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case

BackgroundSince the nineteenth century, a great variety of crossed brainstem syndromes (CBS) have been described in the medical literature. A CBS typically combines ipsilateral cranial nerves deficits to contralateral long tracts involvement such as hemiparesis or hemianesthesia. Classical CBS seem in fact not to be so clear-cut entities with up to 20% of patients showing different or unnamed combinations of crossed symptoms. In terms of etiologies, acute brainstem infarction predominates but CBS secondary to hemorrhage, neoplasm, abscess, and demyelination have been described. The aim of this study was to assess the proportion of CBS caused by a bleeding episode arising from a brainstem cavernous malformation (BCM) reported in the literature.Case presentationWe present the case of a typical Foville syndrome in a 65-year-old man that was caused by a pontine BCM with extralesional bleeding. Following the first bleeding episode, a conservative management was decided but the patient had eventually to be operated on soon after the second bleeding event.DiscussionA literature review was conducted focusing on the five most common CBS (Benedikt, Weber, Foville, Millard-Gubler, Wallenberg) on Medline database from inception to 2020. According to the literature, hemorrhagic BCM account for approximately 7 % of CBS. Microsurgical excision may be indicated after the second bleeding episode but needs to be carefully weighted up against the risks of the surgical procedure and openly discussed with the patient.ConclusionsIn the setting of a CBS, neuroimaging work-up may not infrequently reveal a BCM requiring complex multidisciplinary team management including neurosurgical advice.

Endoscopic Endonasal Transclival Approach to Ventral Pontine Cavernous Malformation: Case Report.

Ventral medial pontine cavernous malformations are challenging due to the location in eloquent tissue, surrounding critical anatomy, and potential symptomatic bleeding. Conventional approaches, such as anterolateral, lateral and dorsal approach, are associated with high risk of deleterious consequences due to excessive traction and damage to the surrounding tissues. The authors present an endoscopic endonasal approach for the resection of midline ventral pontine cavernous malformations, which follows principles of optimal access to brainstem cavernous malformations as the “two-point method.” No CSF leak or any other complications are obtained. The successful outcomes indicate that an individualized approach should be chosen before the surgery for brainstem cavernous malformations. With the advance of techniques, endoscopic endonasal approach could provide the most direct route to ventral pontine lesions with safety and efficiency.

Holmes tremor in a monocentric series of resected brainstem cavernomas

ObjectSeveral scientific papers report clinical symptoms, indications, complications and outcomes of brainstem cavernous malformation (BSCM) surgery without reporting on the occurrence of postoperative Holmes tremor (HT). Our purpose is to report our experience with HT in a monocentric series of resected brainstem cavernomas. MethodsWe reviewed all the BSCM surgical records between 2002 and 2018 at Saint-Luc University Hospital's Department of Neurosurgery, Brussels and selected patients developing HT postoperatively. Patients’ demographics, symptoms, pre- and postoperative imaging, recurrence and complications were analysed. A PubMed literature review was performed to compare our results with those in the existing literature. ResultsIn a total series of 18 resected BSCM, 5 patients: 1 male and 4 females, with a median age of 51 years (range 29–59 years), developed HT. The median preoperative mRS score was 2 (range 1–4). GTR was achieved in all patients without surgery-related death. BSCM were located in the mesencephalon in 4 patients (80%) who developed HT. Tremor was noticed between ten days and one year after surgery. One patient saw significant improvements to the point of stopping treatment. The median follow-up period was 2 years (range 1–14 years). At the last follow-up, 40% of our patients showed a worse mRS score, 40% stayed unchanged, and 20% improved. ConclusionWe are reporting an original single-center series of patients suffering from HT after BSCM surgery. The risk for HT after surgery is significant for midbrain BSCM. A spontaneous favorable evolution is possible.

Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review

BackgroundHaemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs...

Supracerebellar Infratentorial Infratrochlear Trans-Quadrangular Lobule Approach to Pontine Cavernous Malformations.

Brainstem cavernous malformations with symptomatic hemorrhage have a poor natural history. Those without a pial or ependymal presentation are often observed given the morbidity of resection. Surgical removal is considered only in patients with accessible lesions that have repeated symptomatic hemorrhagic. To describe a novel supracerebellar infratentorial infratrochlear trans-quadrangular lobule approach to safely resect lesions in the upper pons. We use a hybrid paramedian/lateral suboccipital craniotomy in the gravity-dependent supine position. Opening the cerebellomesencephalic fissure over the tentorial surface of the cerebellum brings the trochlear nerve, branches of the superior cerebellar artery, and the quadrangular lobule of the cerebellum into view. Removal of small a portion of the quadrangular lobule defines an entry point on the superomedial aspect of the middle cerebellar peduncle, and a surgical trajectory aimed superior to inferior. A total of 6 patients underwent this approach. All presented with symptomatic hemorrhage and all cavernous malformations were completely resected. Five patients were improved or unchanged with modified Rankin scale scores of 1 or 2. The trans-quadrangular lobule approach allows safe resection of upper pontine cavernous malformations along a superior to inferior trajectory.

Tectal Cavernous Malformation that Manifested as Post-hemorrhagic Obstructive Hydrocephalus: A Surgical Case Report

Brainstem cavernous malformations (BCMs) that present with hemorrhage are known to show a higher risk of rebleeding than that associated with cavernous malformations at other sites. We report a surgical case of a tectal cavernous malformation that manifested with post-hemorrhagic obstructive hydrocephalus in a 69-year-old-woman who presented with sudden headache and impaired consciousness. Computed tomography (CT) revealed tectal hemorrhage and acute hydrocephalus. Emergency ventricular drainage was performed; however, the patient's level of consciousness showed only slight improvement. CT performed on day 20 revealed a gradual increase in the size of the hemorrhagic area, suggestive of cavernous malformation-induced rebleeding. We performed microsurgical total resection of the midbrain mass via an occipital transtentorial approach, 5 weeks after onset. Postoperatively, the patient's level of consciousness and right hemiparesis recovered completely, her modified Rankin Scale score was 2, and she was independent at the time of discharge. Aggressive surgical resection is strongly recommended in patients with BCMs that manifest with hemorrhage, owing to the high risk of rebleeding and morbidity associated with this complication. This therapeutic strategy should be promptly considered using the appropriate approach based on the patient's health condition.

Identification of the Facial Colliculus in Two-dimensional and Three-dimensional Images.

The facial colliculus (FC), an important landmark for planning a surgical approach to brainstem cavernous malformation (BCM), is a microstructure; therefore, it may be difficult to identify on magnetic resonance imaging (MRI). Three-dimensional (3D) images may improve the FC-identification certainty; hence, this study attempted to validate the FC-identification certainty between two-dimensional (2D) and 3D images of patients with a normal brainstem and those with BCM.In this retrospective study, we included 10 patients with a normal brainstem and 10 patients who underwent surgery for BCM. The region of the FC in 2D and 3D images was independently identified by three neurosurgeons, three times in each case, using the method for continuously distributed test results (0–100). The intra- and inter-rater reliability of the identification certainty were confirmed using the intraclass correlation coefficient (ICC). The FC-identification certainty for 2D and 3D images was compared using the Wilcoxon signed-rank test.The ICC (1,3) and ICC (3,3) in both groups ranged from 0.88 to 0.99; therefore, the intra- and inter-rater reliability were good. In both groups, the FC- identification certainty was significantly higher for 3D images than for 2D images (normal brainstem group; 82.4 vs. 61.5, P = .0020, BCM group; 40.2 vs. 24.6, P = .0059 for the unaffected side, 29.3 vs. 17.3, P = .0020 for the affected side).In the normal brainstem and BCM groups, 3D images had better FC-identification certainty. 3D images are effective for the identification of the FC.

The role of diffusion tensor imaging and tractography in the surgical management of brainstem gliomas.

Diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) have the ability to noninvasively visualize changes in white matter tracts, as well as their relationships with lesions and other structures. DTI/DTT has been increasingly used to improve the safety and results of surgical treatment for lesions in eloquent areas, such as brainstem cavernous malformations. This study aimed to investigate the application value of DTI/DTT in brainstem glioma surgery and to validate the spatial accuracy of reconstructed corticospinal tracts (CSTs). A retrospective analysis was performed on 54 patients with brainstem gliomas who had undergone surgery from January 2016 to December 2018 at Beijing Tiantan Hospital. All patients underwent preoperative DTI and tumor resection with the assistance of DTT-merged neuronavigation and electrophysiological monitoring. Preoperative conventional MRI and DTI data were collected, and the muscle strength and modified Rankin Scale (mRS) score before and after surgery were measured. The surgical plan was created with the assistance of DTI/DTT findings. The accuracy of DTI/DTT was validated by performing direct subcortical stimulation (DsCS) intraoperatively. Multiple linear regression was used to investigate the relationship between quantitative parameters of DTI/DTT (such as the CST score and tumor-to-CST distance [TCD]) and postoperative muscle strength and mRS scores. Among the 54 patients, 6 had normal bilateral CSTs, 12 patients had unilateral CST impairments, and 36 had bilateral CSTs involved. The most common changes in the CSTs were deformation (n = 29), followed by deviation (n = 28) and interruption (n = 27). The surgical approach was changed in 18 cases (33.3%) after accounting for the DTI/DTT results. Among 55 CSTs on which DsCS was performed, 46 (83.6%) were validated as spatially accurate by DsCS. The CST score and TCD were significantly correlated with postoperative muscle strength (r = -0.395, p < 0.001, and r = 0.275, p = 0.004, respectively) and postoperative mRS score (r = 0.430, p = 0.001, and r = -0.329, p = 0.015, respectively). The CST score was independently linearly associated with postoperative muscle strength (t = -2.461, p = 0.016) and the postoperative mRS score (t = 2.052, p = 0.046). DTI/DTT is a valuable tool in the surgical management of brainstem gliomas. With good accuracy, it can help optimize surgical planning, guide tumor resection, and predict the postoperative muscle strength and postoperative quality of life of patients.

Haemorrhagic brainstem cavernous malformation: early and long term functional outcomes after microsurgical resection

Haemorrhagic brainstem cavernous malformation: early and long term functional outcomes after microsurgical resection

SURG-37. SYSTEMATIC REVIEW OF GAMMA-KNIFE RADIOSURGERY AND MICROSURGICAL RESECTION FOR BRAINSTEM CAVERNOUS MALFORMATIONS

Abstract BACKGROUND Although microsurgical resection (MR) remains the gold-standard for the treatment of symptomatic cavernous malformations, some authors have proposed the use of radiosurgical Gamma-Knife Surgery (GKS) for lesions that are deep or eloquent, such as those located in the brainstem. OBJECTIVE Here were analyze the literature regarding patient outcomes following MR or GKS for brain stem cavernous malformations. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A database search of PubMed, Scopus, Embase, and Web of Science was conducted in September 2019. This review included studies evaluating the outcomes of MR or GKS for cavernous malformations located in the brainstem. RESULTS Gross total resection was achieved in the majority of patients and effectively eliminated the risk of recurrent hemorrhage from the operative lesion in studies following the outcomes of MR. GKS reduces the annual hemorrhage rate for patients, although it does not eliminate the cavernous malformation. Both treatment modalities were effective in reducing prior symptomatology. Unlike resection, GKS only reduces the risk of future hemorrhage and does prevent it. CONCLUSIONS Both MR and GKS can improve or stabilize symptoms in patients. However, the therapeutic benefit of GKS may take months to years to take full-effect, resulting in a potential for subsequent hemorrhagic events. MR remains the best treatment option due to its ability to eliminate future bleeding events entirely and should be performed whenever gross total resection is possible.

Multimodal outcome assessment after surgery for brainstem cavernous malformations.

The object of this study was to assess outcome after surgery for brainstem cavernous malformations (BSCMs) using functional, health-related quality of life (HRQOL), and psychological surveys to analyze the interrelation of these measurements, and to compare HRQOL and anxiety and depression scores with those in a healthy population. The authors performed a cross-sectional outcome study of all patients surgically treated for BSCM in their department between January 1, 2003, and December 31, 2019. They assessed functional outcome via the modified Rankin Scale (mRS), health-related quality of life (HRQOL) via the SF-36 and 9-item Life Satisfaction Questionnaire (LISAT-9), cranial nerve and brainstem function using a questionnaire, symptom-based psychological outcome via the Hospital Anxiety and Depression Scale (HADS), and timepoint of a return to previous employment. They analyzed the correlation between absolute (mRS score ≤ 2) and relative (postoperative deterioration in initial mRS score) outcome endpoints and the interrelation of the outcome measures and performed a comparison of HRQOL and HADS scores with findings in a healthy population. Seventy-four patients were eligible for inclusion in the study. HRQOL was impaired after surgery for BSCM compared to that in a healthy population. This impairment was substantial in patients with an unfavorable functional outcome (mRS > 2) but was also present in those with a favorable outcome (mRS ≤ 2) in selected domains. Psychological impairment was negligible in patients with a favorable outcome and grave in those with an unfavorable outcome. LISAT-9 results revealed that brainstem and cranial nerve symptoms reduce satisfaction mainly in self-care abilities for both unfavorable and favorable outcome patients. Among the brainstem and cranial nerve symptoms, balance impairment showed the most significant impact on HRQOL. Absolute outcome endpoints were superior to relative outcome endpoints in reflecting impairment in HRQOL after surgery. The study data can improve patient counseling and decision-making in BSCM treatment and may function as a benchmark. The authors report outcomes after BSCM surgery in high detail, emphasizing the specific impact of cranial nerve and brainstem symptoms on HRQOL. When reporting BSCM surgery outcome, absolute outcome endpoints should be applied.

Assessment and validation of proposed classification tools for brainstem cavernous malformations.

Treatment indications for patients with brainstem cavernous malformations (BSCMs) remain difficult and controversial. Some authors have tried to establish classification tools to identify eligible candidates for surgery. Authors of this study aimed to validate the performance and replicability of two proposed BSCM grading systems, the Lawton-Garcia (LG) and the Dammann-Sure (DS) systems. For this cross-sectional study, a database was screened for patients with BSCM treated surgically between 2003 and 2019 in the authors' department. Complete clinical records, preoperative contrast-enhanced MRI, and a postoperative follow-up ≥ 6 months were mandatory for study inclusion. The modified Rankin Scale (mRS) score was determined to quantify neurological function and outcome. Three observers independently determined the LG and the DS score for each patient. A total of 67 patients met selection criteria. Univariate and multivariate analyses identified multiple bleedings (p = 0.02, OR 5.59), lesion diameter (> 20 mm, p = 0.007, OR 5.43), and patient age (> 50 years, p = 0.019, OR 4.26) as predictors of an unfavorable postoperative functional outcome. Both the LG (AUC = 0.72, p = 0.01) and the DS (AUC = 0.78, p < 0.01) scores were robust tools to estimate patient outcome. Subgroup analyses confirmed this observation for both grading systems (LG: p = 0.005, OR 6; DS: p = 0.026, OR 4.5), but the combined use of the two scales enhanced the test performance significantly (p = 0.001, OR 22.5). Currently available classification systems are appropriate tools to estimate the neurological outcome after BSCM surgery. Future studies are needed to design an advanced scoring system, incorporating items from the LG and the DS score systems.

Using the Lateral Pontine Safe Entry Zone for Resection of Deep-Seated Cavernous Malformations in the Lateral Pons: 2-Dimensional Operative Video.

The retrosigmoid approach is one of the main approaches used in the surgical management of pontine cavernous malformations. It definitely provides a lateral route to large central lesions but also makes possible resection of some ventral lesions as an alternative to the petrosal approaches. However, when these vascular malformations do not emerge on surface, one of the safe corridors delimited by the origin of the trigeminal nerve and the seventh-eight cranial nerve complex can be used.1-5 Baghai et al2 described the lateral pontine safe entry zone in 1982, as an alternative to approaches through the floor of the fourth ventricle when performing tumor biopsies. They advocated a small neurotomy performed right between the emergence of the trigeminal nerve and the facial-vestibulocochlear cranial nerves complex. Accurate image guidance, intraoperative cranial nerve monitoring, and comprehensive anatomical knowledge are critical for this approach.4,5 Knowing the natural history of a brainstem cavernous malformation after bleeding,6 we sought to demonstrate in this video: (1) the use of the retrosigmoid craniotomy in lateral decubitus for resection of deep-seated pontine cavernous malformations; (2) the wide opening of arachnoid membranes and dissection of the superior petrosal vein complex to improve surgical freedom and prevent use of fixed cerebellar retraction; and (3) the opening of the petrosal fissure and exposure of the lateral pontine zone for gross total resection of a cavernous malformation in a 19-yr-old female with a classical crossed brainstem syndrome. She had full neurological recovery after 3 mo of follow-up. The patient consented in full to the surgical procedure and publication of the video and manuscript.

Limited Impact of Serial Follow-Up Imaging in Clinically Stable Patients With Brainstem Cavernous Malformations.

Background: Clinical management of patients with brainstem cavernous malformations (BSCM) is often challenging due to the unpredictable clinical course and lack of high-quality evidence. Nevertheless, radiologic follow-up is often performed routinely. The objective of this work was to investigate whether active follow-up by serial imaging is justified and how planned imaging will impact clinical decision making in absence of clinical progression.Methods: We included all consecutive patients with BSCM treated and followed at our Department between 2006 and 2018.Results: Of 429 patients with CCM, 118 were diagnosed with BSCM (27.5%). Patients were followed for a mean of 8.1 (± 7.4 SD) years. Conservative treatment was recommended in 54 patients over the complete follow-up period, whereas 64 patients underwent surgical extirpation of BSCM. In total, 75 surgical procedures were performed. Over a period of 961 follow-up years in total, routinely performed follow-up MRI in clinically stable patients did not lead to a single indication for surgery.Conclusion: Due to the difficult-to-predict clinical course of patients with BSCM and the relatively high risk associated with surgery, routine imaging is unlikely to have any influence on surgical decision making in clinically stable patients with BSCM.

Surgery for Brainstem Cavernous Malformations: Association between Preoperative Grade and Postoperative Quality of Life.

Brainstem cavernous malformations (BSCMs) are associated with substantial neurologic morbidity, but the literature on quality of life (QoL) after surgical treatment is limited. There is a need for validating the clinical utility of current grading scales for cavernous malformations. To assess outcome of surgery for BSCMs and validate how outcome is associated with current grading scales for cavernous malformations. We retrospectively reviewed a single-surgeon series of patients with BSCM treated surgically during a 10-yr period. Outcome was categorized according to modified Rankin Scale (mRS), and QoL was assessed by interviewing patients using Short Form 36 (SF-36) Health Survey and comparing results with the normative population. The mRS and QoL were correlated with the Lawton BSCM grading scale and with the Zabramski classification of cavernous malformations. The study included 22 patients (12 males and 10 females; median age 58 yr). No mortality related to the BSCM surgery occurred, and none were in vegetative state. In SF-36, 70% of patients reported a physical and mental functioning noninferior compared to the general population of comparative age and gender group. There was a significant positive correlation between the Lawton BSCM grading and the postoperative mRS score and QoL. Outcome of surgery for BSCM was good, as assessed by mRS and QoL. The Lawton grading scale for BSCMs correlated significantly with the postoperative mRS score and QoL, suggesting this grading scale may become a useful clinical tool for treatment prognostication at the individual level.

Stereotactic laser interstitial thermal therapy for brainstem cavernous malformations: two preliminary cases

Brainstem cavernous malformations (CMs) often have high hemorrhage rates and significant posthemorrhage morbidity. The authors present two cases in which magnetic resonance thermography-guided laser interstitial therapy was used for treatment of pontine CMs after recurrent hemorrhage. Both patients showed significant symptomatic improvement and were hemorrhage-free at 12- and 6-month follow-up, respectively. Each had radiographic evidence of lesion involution on serial follow-up imaging. These early results demonstrate this treatment modality may be technically safe; however, larger case numbers and longer follow-up are needed to demonstrate efficacy.