Surgical Treatment Of Cavernous Malformations Research Articles

Cavernous Malformations: What They Have Taught Us.

Cavernous Malformations: What They Have Taught Us.

ДИФЕРЕНЦІАЛЬНА ДІАГНОСТИКА ЦЕРЕБРАЛЬНИХ СУДИННИХ ВАД І ОБ’ЄМНИХ НОВОУТВОРЕНЬ ФУНКЦІОНАЛЬНО ВАЖЛИВИХ ДІЛЯНОК МОЗКУ: КРИТЕРІЇ ВИБОРУ НЕЙРОХІРУРГІЧНОЇ ТАКТИКИ

Introduction. We believe, that in the planning of the surgical removal of cerebral vascular malformations (CVM) of eloquent brain areas, a question of whether they include the functionally sustainable brain tissue remains relevant. The question of whether the surgical procedure is safe is paramount. Aim. To assess the value of magnetic resonance (MR) tractography in deciding on the tactics of surgical treatment of CVM through comparison with morphological studies. Study methods. A review of the literature concerning the surgical treatment of cavernous malformations (CM) and arteriovenous malformations (AVM) localized in eloquent brain areas (EBA). Four patients with CVM of EBA were selected based on the availability of MR tractography data and histologic specimens. The method of optical microscopy was used to study microslides stained with the classic (hematoxylin-eosin) and specialized methods (Masson’s and Hart’s methods). Results. Patients’ MR-tractography data showed the presence of conductive paths in the tissues of CM and AVM and the reduced fractional anisotropy in the regions of interest, which indicates their involvement. During optical microscopy of specimens of CVMs, we found brain tissues between pathological vessels. To our opinion, this explains the visualization of conducting paths in CVMs during MR tractography. Conclusions. When planning surgeries in case of CVMs, attention should be paid to the results of conductive path visualization. According to MR tractography and morphological data, in some cases, there is brain parenchyma in the structure of CMs and AVMs, which may require additional attention in deciding on the radical resection of CVMs of EBAs.

DIAGNOSIS AND FEATURES OF THE SURGICAL TREATMENT OF CAVERNOUS MALFORMATIONS OF THE BRAIN

The article presents an analysis on the modern aspects of diagnosis and surgical treatment of cavernous malformations of the brain. The modern approaches to surgical treatment depending on the type of clinical course of cavernous angiomas you can see in this paper.

Application of functional imaging, neuronavigation, and intraoperative MR imaging in the surgical treatment of brain cavernomas

ABSTRACT Objective: The aim of this study was to investigate whether preoperative functional imaging and intraoperative magnetic resonance imaging (iMRI) facilitate surgery and improve outcomes in the surgical treatment of cavernous malformations of the brain (CM). Materials and Methods: Retrospective data analysis was performed for consecutive patients diagnosed with a CM who underwent surgical treatment at a single academic institution during a 12 year period. A total of 91 patients was eligible for analysis with a mean age of 38.8 ± 15 years (range 2–72 years). Altogether, 89.0% of CM had supratentorial and 11% infratentorial location. Results: Neuronavigation and iMRI was used in 69 (75.8%) patients with 28 (30.8%) of them together with functional MRI (fMRI) all in the supratentorial location. In 4.3% (3 cases) an intraoperative second-look surgery was performed. Altogether, a complete resection was achieved in 93% of the patients. In supratentorial surgeries, surgical times were significantly shorter in the fMRI group (p = 0.036), but altogether, infratentorial CM surgery took significantly longer (p = 0.014). Moreover, in the fMRI group, reduction of seizure medication was achieved significantly more often (p = 0.026). At an FU of 6.1± 3.1 years, 96% of the patients were assessed modified Rankin Scale 0 or 1. Conclusion: Neuronavigation together with intraoperative and functional MRI had a significant impact on resection amount, surgical time, and neurological and seizure outcome of supratentorial CM. In addition, iMRI was beneficial in few-selected cases.

Intraoperative video-angiography in surgery for spinal intramedullary cavernous malformations: first experience of its application at the Burdenko Neurosurgical Center

Spinal intramedullary cavernous malformations are a rare vascular pathology of the central nervous system. They account for 3-5% of spinal cord diseases. The clinical picture in patients with cavernous malformations varies from an asymptomatic course to gross neurological deficit in the case of bleeding from a malformation. Due to the lack of reliable methods for predicting the development of bleeding, the need for surgical treatment of asymptomatic patients remains a relevant and open topic for discussion. The goal of surgical treatment of cavernous malformations is to minimize the risk of repeated hemorrhages and gross neurological deficits in patients. Intraoperative indocyanine green video angiography is a promising technique for intraoperative visualization of the size and adherence area of a cavernous malformation to the spinal cord tissue. This increases the radicality of cavernous malformation resection and minimizes intraoperative risks for the patient.

Supratentorial Cavernous Malformations Involving the Corticospinal Tract and Sensory Motor Cortex: Treatment Strategies, Surgical Considerations, and Outcomes.

Cavernous malformations (CMs) are congenital malformations and may be located anywhere in the brain. We present a series of CMs located close to or inside of the motor-sensory cortex or corticospinal tract (CST) with clinical onset due to hemorrhage or mass effect. In such cases, surgery becomes an acceptable option. To evaluate the role of diffusion tensor imaging (DTI), functional-magnetic-resonance imaging (fMRI), intraoperative neurophysiological monitoring, neuronavigation, and brain-mapping and the clinical results of surgical treatment of CMs in this critical location. The study included 54 patients harboring 22 cortical and 32 deep locations. This series was distinct because in group I, where the DTI was not obtained, and in the group II, where this evaluation was performed. The postoperative permanent morbidity rate was 4% in the historical group for the deeper CMs, and there was no morbidity in the second group. DTI and fMRI permitted us to estimate the distance between the CMs and both the cortical activation cluster and the pyramidal tract. These data, in addition to intraoperative mapping and monitoring, made it necessary for us to perform a partial resection in 2 cases in the second series. CMs are congenital lesions and CST fibers can run directly on their surface. Integration of fMRI and DTI data with intraoperative functional monitoring and direct cortical and subcortical mapping are mandatory to accomplish an optimal resection, tailoring the best surgical approach to the acceptable morbidity. A subtotal resection could be considered an option for deep locations.

Treatment of cavernous malformations in supratentorial eloquent areas: experience after 10 years of patient-tailored surgical protocol

Eloquent area surgery has become safer with the development of intraoperative neurophysiological monitoring and brain mapping techniques. However, the usefulness of intraoperative electric brain stimulation techniques applied to the management and surgical treatment of cavernous malformations in supratentorial eloquent areas is still not proven. With this study, we aim to describe our experience with the use of a tailored functional approach to treat cavernous malformations in supratentorial eloquent areas. Twenty patients harboring cavernous malformations located in supratentorial eloquent areas were surgically treated. Individualized functional approach, using intraoperative brain mapping and/or neurophysiological monitoring, was utilized in each case. Eleven patients underwent surgery under awake conditions; meanwhile, nine patients underwent asleep surgery. Total resection was achieved in 19 cases (95%). In one patient, the resection was not possible due to high motor functional parenchyma surrounding the lesion tested by direct cortical stimulation. Ten (50%) patients presented transient neurological worsening. All of them achieved total neurological recovery within the first year of follow-up. Among the patients who presented seizures, 85% achieved seizure-free status during follow-up. No major complications occurred. Intraoperative electric brain stimulation techniques applied by a trained multidisciplinary team provide a valuable aid for the treatment of certain cavernous malformations. Our results suggest that tailored functional approach could help surgeons in adapting surgical strategies to prevent patients' permanent neurological damage.

Surgical Management and Functional Outcomes of Cavernous Malformations Involving the Medulla Oblongata

The aim of this study was to evaluate the clinical features, surgical complications, and functional outcomes of the surgical treatment of patients with cavernous malformations (CMs) involving the medulla oblongata. The charts of 69 patients undergoing surgical treatment of CMs in the medulla oblongata, pontomedullary, and cervicomedullary junctions between 2011 and 2017 were retrospectively reviewed. Patient demographics, lesion characteristics, operative documents, and patient outcomes were examined. Of the 69 patients, the male-to-female ratio was 1.3. The mean patient age was 32.6 years, and the mean mRS score was 2.7 on admission. Postoperatively, 21 patients (30.4%) had deficits of cough reflexes, and 6 patients (8.7%) experienced respiratory rhythm disorder and dyspnea. The mean follow-up duration was 35.3 months. At the last follow-up evaluation, the mean mRS score was 1.8, and 53 patients (80.3%) had favorable outcomes, with mRS scores ≤2. The conditions of the patients improved in 45 cases (68.2%), remained unchanged in 11 cases (16.7%), and worsened in 10 cases (15.1%) relative to their preoperative baseline. The independent adverse factors for long-term functional outcome were increased age, multiple hemorrhages, presence of developmental venous anomalies, and lack of perilesional edema. Respiratory dysfunction and deficits of cough reflexes can commonly occur during the early postoperative period for surgical resection of CMs involving the medulla oblongata. Favorable functional outcomes can be achieved by surgery, especially for younger patients who experience fewer hemorrhages and have lesions with perilesional edema and the absence of developmental venous anomalies.

Surgical Treatment of the Medullary Cavernous Malformations: 53 Cases

The aim of this study was to investigate patient clinical features, surgical complications and outcomes, and the prognostic risk factors of surgical treatment of cavernous malformations (CMs) involving the medulla oblongata. The charts of 53 patients who underwent surgical treatment for CMs involving the medulla oblongata between 2011 and 2017 were reviewed retrospectively. Patient demographics, lesion characteristics, operative documents, and patient outcomes were examined. The study population consisted of 53 patients, with a male/female ratio of 1.4 and a mean age of 32.6 years. Eighteen patients (34.0%) had respiratory dysfunction, and 2 patients (3.8%) had cardiac instabilities, preoperatively. The mean modified Rankin Scale score was 2.7 on admission. Gross total resection was achieved in 52 patients (98.1%). Postoperatively, 23 patients (43.4%) had respiratory dysfunction, and 16 patients (30.2%) had dysphagia or cough. The mean follow-up duration was 35.7 months. At the last follow-up evaluation, the mean modified Rankin Scale score was 1.7, and 42 patients (84%) had favorable outcomes, with mRS scores ≤2. The conditions of the patients improved in 34 cases (68%), remained unchanged in 10 cases (20%), and worsened in 6 cases (12%) relative to the preoperative baseline. The independent adverse factors for long-term outcome were age ≥50 years and increased time of reservation of tracheal intubation after surgery. Surgical treatment of CMs involving the medulla oblongata was challenging, notably, perioperative respiratory dysfunction, with which patients tend to have unfavorable long-term outcomes, especially for elder patients.

Surgical treatment of cavernous malformations involving medulla oblongata

Surgical treatment of cavernous malformations (CMs) involving medulla oblongata is more difficult than the CMs in other sites because of the surrounding vital structures. However, the distinctive features and treatment strategies have not been well illustrated. Therefore, we enrolled a total of 19 patients underwent surgical treatment of CMs involving medulla oblongata in our hospital from August 2008 to August 2014. The clinical features, surgical management and clinical outcome of these patients were retrospectively analyzed, while our institutional surgical indications, approaches and microsurgical techniques were discussed. In our study, gross total resection was achieved in 17 patients and subtotal resection in 2. Two patients underwent emergency surgeries due to severe and progressive neurological deficits. The postoperative new-onset or worsened neurological deficits occurred in 6 patients. After a mean follow-up of 45.8±22.2months, the neurological status was improved in 10 patients and remained stable in 7. The mean modified Rankin Scale (mRS) was 2.58±1.26 preoperatively, 3.11±0.99 postoperatively and 1.84±1.42 at the recent follow-up, respectively. During the follow-up period, no rehemorrhage and recurrence occurred, and the residual lesions remained stable. We recommended surgical resection of symptomatic CMs involving medulla oblongata via optimal approaches, feasible entry zones and meticulous microsurgical techniques in attempting to achieve safe resection and favorable outcome. The clinical features, surgical indications, timing and microsurgical techniques of this special entity should be distinctive from the brainstem cavernous malformations in other sites.

Surgical Treatment of Cavernous Malformations Involving the Posterior Limb of the Internal Capsule: Utility and Predictive Value of Preoperative Diffusion Tensor Imaging

The surgical treatment of cavernous malformations involving the posterior limb of the internal capsule (PLIC-CMs) is challenging. The aim of this study was to determine the utility and predictive value of preoperative diffusion tensor imaging (DTI) in the surgical treatment of PLIC-CMs. Patients with PLIC-CMs who were surgically treated between September 2012 and June 2015 were reviewed. All patients underwent preoperative DTI. Three major fiber tracts were selected for evaluation: 1) corticospinal tract (CST); 2) arcuate fasciculus (AF); and 3) optic radiation (OR). The utility of preoperative DTI for surgical approach selection and intraoperative navigation was documented. An involvement grading system of the major fibers was applied to determine the predictive value of preoperative DTI. A last modified Rankin Scale (mRS) score of 0-2 was considered a good outcome, and a last mRS >2 was considered a poor outcome. Thirteen patients with 13 PLIC-CMs were reviewed in this study. All the lesions were radically resected via the corridor formed by CST, AF, and OR. None of the patents suffered from mRS >3, and 7 patients (53.8%) got good outcomes at the last clinic visit. The difference between the preoperative mRS scores and last mRS scores was not significant (P= 0.673). The involvement grade of the fiber tracts was significantly associated with the surgical outcome (P= 0.011). Preoperative DTI may be a promising tool to determine the surgical approach and predict the surgical outcomes in patients with PLIC-CMs.

Supracerebellar Infratentorial Approach to Cavernous Malformations of the Brainstem

The supracerebellar infratentorial (SCIT) approach can be performed at the midline (median variant), lateral to the midline (paramedian variant), or at the level of the angle formed by the transverse and sigmoid sinuses (extreme lateral variant). We analyzed our experience with SCIT approaches for the surgical treatment of cavernous malformations of the brainstem (CMBs). Demographic, clinical, radiologic, and surgical data from 45 patients (20 males and 25 females; mean age, 36.2 years) with CMBs surgically removed through SCIT approaches were reviewed retrospectively. Anatomic information was explored using cadaver head dissection. Twenty-three lesions were in the midbrain, 3 were at the midbrain and extended to the thalamus, 9 were at the pontomesencephalic junction, and 10 were in the upper pons. All patients presented with hemorrhage. The median variant was used in 13 patients, the paramedian variant in 9, and the extreme lateral variant in 23. Intraoperatively, all CMBs were associated with a developmental venous anomaly. At last follow-up, 88% of the patients were the same or better. After a mean follow-up of 20 months, their mean Glasgow Outcome Scale score was 4.1. SCIT approaches provide excellent exposure to CMBs located at the posterior incisural space, not only in the midline but also in the posterolateral surface of the upper pons and midbrain. Careful preoperative planning and neuronavigational assistance are needed to determine the best angle of attack and trajectory for SCIT approaches. Refined microsurgical techniques are paramount to achieve safe surgical removal of CMBs with good outcomes.