Resection Of Cerebral Cavernous Malformations Research Articles

Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience.

BackgroundFeatures associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet. MethodsClinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0–1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale. ResultsA total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II). ConclusionsSurgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.

Cavernous Malformations: What They Have Taught Us.

Cavernous Malformations: What They Have Taught Us.

Functional outcome after pediatric cerebral cavernous malformation surgery

The purpose of this study was to investigate the functional outcome following surgical resection of cerebral cavernous malformations (CCM) in pediatric patients. We screened our institutional database of CCM patients treated between 2003 and 2021. Inclusion regarded individuals younger or equal than 18 years of age with complete clinical baseline characteristics, magnetic resonance imaging dataset, and postoperative follow-up time of at least three months. Functional outcome was quantified using the modified Rankin Scale (mRS) score and assessed at admission, discharge, and last follow-up examination. The primary endpoint was the postoperative functional outcome. As a secondary endpoint, predictors of postoperative functional deterioration were assessed. A total of 49 pediatric patients with a mean age of 11.3 ± 5.7 years were included for subsequent analyses. Twenty individuals (40.8%) were female. Complete resection of the lesion was achieved in 44 patients (89.8%), and two patients with incomplete resection were referred for successive remnant removal. The mean follow-up time after surgery was 44 months (IQR: 13 – 131). The mean mRS score was 1.6 on admission, 1.7 at discharge, and 0.9 at the latest follow-up. Logistic regression analysis adjusted to age and sex identified brainstem localization (aOR = 53.45 [95%CI = 2.26 − 1261.81], p = .014) as a predictor of postoperative deterioration. This study indicates that CCM removal in children can be regarded as safe and favorable for the majority of patients, depending on lesion localization. Brainstem localization implies a high risk of postoperative morbidity and indication for surgery should be balanced carefully. Minor evidence indicates that second-look surgery for CCM remnants might be safe and favorable.

A Japanese case of successful surgical resection of cerebral cavernous malformations with a CCM2 mutation

AbstractCerebral cavernous malformations (CCMs) are congenital abnormalities of cerebral vessels. Surgical resection is rarely considered for the control of epilepsy in a first seizure patient with vascular malformation. In contrast, lesions that produce repetitive or progressive symptoms should be considered for surgical resection as treatment. Herein, we report a Japanese patient with a CCM2 mutation, c.609G>A (p.K203K) substitution, who showed drug‐resistant epilepsy and dramatic improvement after surgical resection.

Overview of cerebral cavernous malformations: comparison of treatment approaches

ObjectivesThe comparison of treatment efficacy for cerebral cavernous malformations (CCMs) has not yet been well researched.DesignPubMed, Cochrane Library, Science Direct, ISI Web of Science, Embase and additional sources were searched...

Recurrent brainstem cavernous malformations following primary resection: blind spots, fine lines, and the right-angle method

Proximity of brainstem cavernous malformations (BSCMs) to tracts and cranial nerve nuclei make it costly to transgress normal tissue in accessing the lesion or disrupting normal tissue adjacent to the lesion in the separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult to avoid leaving a remnant on occasion. Recurrences require operative intervention, which may increase morbidity, lengthen recovery, and add to overall costs. An approximately 20-year experience with patients with recurrent BSCM lesions following primary microsurgical resection was reviewed. A prospectively maintained database of 802 patients who underwent microsurgical resection of cerebral cavernous malformations during 1997-2018 was queried to identify 213 patients with BSCMs. A retrospective chart review was conducted for patients with recurrent BSCM after primary resection who required a second surgery. Fourteen of 213 patients (6.6%) underwent repeat resection for recurrent BSCM. Thirty-four hemorrhagic events were observed among these 14 patients over 576 patient-years (recurrent hemorrhage rate, 5.9% per year; median discrete hemorrhagic events, 2; median time to rehemorrhage, 897 days). BSCM occurred in the pons in 10 cases, midbrain in 2 cases, and medulla in 2 cases. A blind spot in the operative corridor was the most common cause of residual BSCM (9 patients). All recurrent BSCMs were removed completely, although 2 patients each required 2 operations to treat recurrence. Twelve patients had unchanged or improved modified Rankin Scale scores at last clinical evaluation compared with admission, and 2 patients had worse scores. Recurrence was more common among patients who were operated on in the first versus the second half of the series (8.5% vs 4.7%). The 6.6% rate of BSCM recurrence requiring reoperation reflects the fine lines between complete resection and recurrence and between safe and harmful surgery. The detection of remnants is difficult postoperatively and remains so even at 6 months when the resection bed has healed. The 5.9% annual hemorrhage risk associated with recurrent BSCM in this experience is consistent with that reported for unoperated BSCMs. The right-angle method helps to anticipate blind spots and meticulously inspect the resection cavity for residual BSCM during surgery. A low percentage of recurrent BSCM (5%-10%) ensures ongoing effort toward an acceptable balance of safety and completeness.

Commentary: Minimally Invasive Parafascicular Surgery for Resection of Cerebral Cavernous Malformations Utilizing Image-Guided BrainPath System

Commentary: Minimally Invasive Parafascicular Surgery for Resection of Cerebral Cavernous Malformations Utilizing Image-Guided BrainPath System

Galvos smegenų kaverninė malformacija

Galvos smegenų kaverninė malformacija (KM, kavernoma, kaverninė angioma, kaverninė hemangioma) – tai įgimtas krauja­gyslinis darinys, sudarytas iš kompaktiškai išsidėsčiusio išsiplėtusių kapiliarų rezginio, kuriame nėra smegenų parenchimos. Dažnai kavernomų simptomatikos pasireiškimas susijęs su pakraujavimu. Tačiau kavernomos gali būti besimptomės, jos nu­statomos atsitiktinai. Kasmetinis kamieno kavernomų pakraujavimo dažnis – nuo 2,3 % iki 4,1 %.Todėl dauguma sunkių ži­dinių tampa neurochirurgijos centrų tikslu. Giliai esančių bei kamieno židinių chirurgija yra ne tokia sėkminga. Kavernomų simptomatika priklauso nuo židinio lokalizacijos. Apie 80 % atvejų kavernomos yra viršdangtinės. Dažniausiai pažeidžiamos kaktinė bei smilkininė skiltys, požievinė zona. Būdingiausi simptomai yra epilepsija ir traukuliai. Šie simptomai yra susiję su kaverninės malformacijos pakraujavimu. Renkantis chirurginį gydymą svarbu įvertinti židinio anatomiją ir lokalizaciją atlikus magnetinio rezonanso tomografiją (MRT). Radikalus kavernomos chirurginis pašalinimas yra vienintelis veiksmingas gydymo metodas.MRT yra jautriausias ir specifiškiausias kavernomų diagnostikos metodas. Mažas kavernomas rutininiu MRT gali būti sunku diagnozuoti.

Endoport-assisted microsurgical resection of cerebral cavernous malformations

The aim of this case series is to describe the surgical technique and postoperative outcomes for endoport-assisted microsurgical resection (EAMR) of cerebral cavernous malformations (CCM). Significant manipulation of subcortical white matter tracts may be necessary for the successful resection of CCM located in deep brain regions. Minimally invasive neurosurgical devices such as endoport systems can decrease disruption of the cortex and white matter tracts overlying deep-seated CCM through small cranial and dural openings. The role of endoport technology in modern CCM surgery is incompletely understood. Three patients with symptomatic CCM underwent EAMR at our institution using the BrainPath endoport system (NICO Corporation, Indianapolis, IN, USA). Complete resection was achieved in two patients. One patient with a large 4.5cm callosal CCM was left with a small residual lesion. There were no postoperative complications and all patients were functionally independent (modified Rankin Scale score 2 or less) at follow-up. Based on our initial experience with EAMR for CCM we believe the endoport can be an effective alternative to traditional retractor systems. Due to the nature of the small craniotomy and durotomy performed for endoport placement EAMR has the potential to improve surgical outcomes by reducing postoperative pain, analgesic requirements and hospital stays. Therefore, EAMR may be considered for appropriately selected CCM patients, although additional experience is necessary to improve our understanding of its role in CCM management.

Longitudinal changes in seizure outcomes after resection of cerebral cavernous malformations in patients presenting with seizures: a long-term follow-up of 46 patients.

Seizure is the most common presentation in patients with cerebral cavernous malformations (CCMs). Although many articles have documented seizure outcomes after resection of CCM, few have conducted long-term follow-ups; thus, the fluctuating seizure outcomes have been neglected. The purpose of this study is to describe long-term postoperative seizure outcomes in patients with CCM and to compare seizure outcomes between patients with sporadic seizures and those with chronic seizures. Forty-six patients with CCM presenting with seizures underwent surgery. The male-to-female ratio was 1:1, and the average age at initial seizure onset was 27.6 years. The mean preoperative seizure duration was 42.7 months. Patients were divided into two groups: a chronic group (N = 20) and a sporadic group (N = 26) according to seizure frequency and duration. The mean postoperative follow-up duration was 96.3 months, and the postoperative seizure outcomes were checked annually based upon Engel's classification. After the first year of follow-up, 80.8 % of the sporadic group and 75.0 % of the chronic group were evaluated as Engel class I. These rates increased to 100.0 % and 90.0 %, respectively, at the eighth year of follow-up. Overall, 29 (63.0 %) of the 46 patients experienced changes in seizure outcomes over the follow-up period. Despite their delayed improvements, the chronic group showed less favorable outcomes throughout follow-up (p = 0.025). Long-term follow-up is indispensable for accurately assessing postoperative seizure outcomes because these outcomes change continuously. We recommend earlier surgery to achieve seizure-free status in patients with CCM. However, even in the chronic group, surgery is recommended, considering the overall delayed improvement.

Usefulness of Preoperative Surgical Simulation with Three-Dimensional Fusion Images for Resection of Cerebral Cavernous Malformations Near Broca's Area.

Treating subcortical brain lesions in or near eloquent areas is challenging not only because lesions must be resected while preserving brain tissue involved in essential functions, but also because lesions often cannot be easily identified from the surface of the brain. Here, we report 2 cases of cerebral cavernous malformations near Broca's area. In both cases, lesions were surgically removed by utilizing three-dimensional fusion images created using preoperative magnetic resonance imaging and computed tomography data. Excisions were completed without any worsening of speech function, and the use of presurgical simulations was found to be useful in the design and execution of the actual operations. The technique described in this report serves as a useful tool in simulating surgical strategies by using brain gyri and sulci as surgical landmarks. Furthermore, in contrast to other intraoperative techniques, this method can aid in shortening the duration of surgery and can help limit damage to eloquent areas of the brain.

Predictors of seizure freedom in the surgical treatment of supratentorial cavernous malformations

Seizures are the most common presenting symptom of supratentorial cerebral cavernous malformations (CCMs) and progress to medically refractory epilepsy in 40% of patients. Predictors of seizure freedom in the resection of CCMs are incompletely understood. The authors systematically reviewed the published literature on seizure freedom following the resection of supratentorial CCMs in patients presenting with seizures. Seizure outcomes were stratified across 12 potential prognostic variables. A total of 1226 patients with supratentorial CCMs causing seizures were identified across 31 predominantly retrospective studies; 361 patients had medically refractory epilepsy. Seventy-five percent of the patients were seizure free after microsurgical lesion removal, whereas 25% continued to have seizures. All patients had had preoperative seizures and > 6 months of postoperative follow-up. Modifiable predictors of postoperative seizure freedom included gross-total resection (OR 36.6, 95% CI 8.5-157.5) and surgery within 1 year of symptom onset (OR 1.83, 95% CI 1.30-2.58). Additional prognostic indicators of a favorable outcome were a CCM size < 1.5 cm (OR 15.4, 95% CI 5.2-45.4), the absence of multiple CCMs (OR 2.02, 95% CI 1.13-3.60), medically controlled seizures (OR 2.38, 95% CI 1.29-4.39), and the lack of secondarily generalized seizures (OR 3.33, 95% CI 2.09-5.30). Other factors, including extended resection of the hemosiderin ring, were not significantly predictive. In the surgical treatment of supratentorial CCMs, gross-total resection and early operative intervention may improve seizure outcome. While surgery should not be considered the first-line treatment for CCM-related epilepsy, it is important to understand the variables associated with seizure freedom in CCM resection given the considerable morbidity and diminished quality of life associated with epilepsy.