Symptomatic Brainstem Cavernoma Research Articles

Microsurgery of Brainstem Cavernoma: Challenges and Outcomes

Cavernous malformation of brainstem is at increased risk of hemorrhage compared to supratentorial cavernomas. Increased morbidity associated with brainstem cavernoma (BCs) is defined by the inherent eloquence of the surrounding structures. At present watchful waiting, microsurgical resection and gamma knife surgery are the treatment modalities for symptomatic brainstem cavernoma. However, in the resource limited settings microsurgical excision by selecting an appropriate corridor can help in gross total removal in the meantime improving the neurological deficit and patient satisfaction. In this case series we have reviewed cavernomas of midbrain and pons, the technical difficulty with its management and its outcomes.

Timing of Surgery and Surgical Strategies in Symptomatic Brainstem Cavernomas: Review of the Literature.

Brainstem cavernomas (BSCs) are angiographically occult, benign low flow vascular malformations that pose a significant surgical challenge due to their eloquent location. The present study includes an extensive review of the literature and three illustrative cases of BSC with emphasis on the timing of surgery: surgical approaches, usage of intraoperative monitoring, and complication avoidance. A systematic search was performed using the PubMed database was from January 1, 1999, to June 2018. The relevant articles were reviewed with particular attention to hemorrhage rates, timing of surgery, indications for surgery, surgical approaches, and outcome. Along with this, a retrospective analysis of three cases of symptomatic BSC, who were operated for the same, during the year 2018 in our institute was conducted. All the three patients presented with at least 1 episode of hemorrhage before surgery. Of these, one patient was operated immediately due to altered sensorium whereas the other two were operated after at least 4 weeks of the hemorrhagic episode. The patients who were operated in the subacute phase of bleed were seen to have liquefaction of hematoma, thus providing a good surgical demarcation and thereby reduced surgery-related trauma to the surrounding eloquent structures. Two patients improved neurologically during the immediate postoperative period, whereas one had transient worsening of neurological deficits during the immediate postoperative period in the form of additional cranial nerve palsies which completely improved on follow-up after 2 months. Radical resection is recommended in all patients with symptomatic BSCs. Surgery should be considered after the first or the second episode of hemorrhage as multiple rebleeds can cause exacerbation of deficits and sometimes mortality as well. Considering surgical timing, anywhere between 4 and 6 weeks or the subacute phase of the hemorrhage is considered appropriate. The aims of surgical intervention must be to improve preoperative function, minimize surgical morbidity and to reduce hemorrhagic rates. In spite of the significant surgical morbidity associated with BSCs, appropriate patient selection, meticulous surgical planning with adjuncts such as intraoperative monitoring and neuronavigation will go a long way in avoidance of major postoperative complications.

Rebleeding and Outcome in Patients with Symptomatic Brain Stem Cavernomas

Purpose: We sought to evaluate the long-term functional outcomes and identify the potential risk factors for rebleeding in patients with brain stem cavernous malformations (BCMs) who presented with hemorrhages and were surgically or conservatively treated and prospectively monitored. Methods: From January 1990 to July 2015, we included patients with first hemorrhagic episodes secondary to single BCMs. Modified Rankin score (mRS) was used for neurological status assessment. Univariate and multivariate regression statistics were used to identify the risk factors for rebleeding. Results: A total of 99 patients with BCMs hemorrhages were included (59 [59.6%] women, mean age 37± 13 years). As initial treatments, 37 patients (37.4%) underwent surgery and 62 (62.6%) received conservative treatment. The median follow-up was 3.33 years (interquartile range 1.16-7 years; 408.3 patient/years). The rebleeding rate by patient/year was 10% in conservatively treated patients. Deterioration was significantly more frequent in patients with rebleeding (p = 0.0001). At the end of the follow-up, the mRS were favorable in 49 patients (65.3%) without rebleeding, whereas only 8 (33.3%) with rebleeding evolved to favorable outcomes (p = 0.006). Lesion size >18 mm (hazards ratio, HR 3.34, 95% CI 1.54-7.26; p = 0.0001) and ventral location or crossing the brain stem's midpoint (HR 2.5, 95% CI 1.14-5.46; p = 0.022) were associated with a major risk of rebleeding in the univariate analysis, but only a lesion >18 mm remained statistically significant (HR 2.7, 95% CI 1.2-6.21; p = 0.016) in the multivariate analysis. Conclusion: A lesion size >18 mm was the principal factor associated with hemorrhage recurrence. The overall functional outcome was good. However, significant morbidity was attributable to rebleeding.

Surgical management of symptomatic brain stem cavernoma in a developing country: technical difficulties and outcome.

Brain stem cavernomas (BSCs) are angiographically occult vascular malformations in an intricate location. Surgical excision of symptomatic BSCs represents a neurosurgical challenge especially in developing countries. We reviewed the clinical data and surgical outcome of 24 consecutive cases surgically treated for brain stem cavernoma at the Neurosurgery Department, Alexandria University, between 2006 and 2014. All patients were followed up for at least 12months after surgery and the mean follow-up period was 45months. All patients suffered from at least two clinically significant hemorrhagic episodes before surgery. There were 10 males and 14 females. The mean age was 34years (range 12 to 58years). Fourteen cases had pontine cavernomas, 7 cases had midbrain cavernomas, and in 3 cases, the lesion was found in the medulla oblongata. The most commonly used approach in this series was the midline suboccipital approach with or without telovelar exposure (9 cases). There was a single postoperative mortality in this series due to pneumonia. Fourteen cases (58.3%) showed initial worsening of their preoperative neurological status, most of which was transient and only three patients had permanent new deficits and one case had a permanent worsening of her preoperatively existing hemiparesis. There was neither immediate nor long-term rebleeding in any of our cases. In spite of the significant associated risks, surgery for BSCs in properly selected patients can have favorable outcomes in most cases. Surgery markedly improves the risk of rebleeding and should be considered in patients with accessible lesions.

Brainstem cavernomas: a surgical challenge

The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment.

Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques

This study reviewed surgical experience with brainstem cavernomas in an attempt to define optimal surgical approaches and risks associated with surgical management. Clinical courses were retrospectively reviewed for 36 consecutive patients (12 men, 24 women; mean age, 42 years) who underwent microsurgical resection of brainstem cavernomas between 1996 and 2006. Medical records, surgical records, and neuroimaging examinations were evaluated. All 36 patients presented with > or =1 hemorrhage from the cavernomas and preoperatively displayed some neurological symptoms. Surgical approach was midline suboccipital for 16 pontine and/or medullary cavernomas under the floor of the fourth ventricle, retrosigmoid for 10 lateral mesencephalic, pontine, and/or medullary cavernomas, occipital transtentorial for 2 thalamomesencephalic and 3 mesencephalic cavernomas, combined petrosal for 2 pontine cavernomas, and other for 3 cavernomas. Complete resection according to postoperative magnetic resonance imaging was achieved in 33 of 36 patients. No mortality was encountered in this study. New neurological deficit occurred in the early postoperative period for 18 patients, but was transient in 15 of these. Neurological state as of final follow-up was improved in 16 patients (44%), unchanged in 17 (47%), and worsened in 3 (8%) compared with preoperatively. In conclusion, symptomatic brainstem cavernomas should be considered for surgical treatment. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory.

SYMPTOMATIC BRAINSTEM CAVERNOMAS

The goal of this study was to analyze the natural history of symptomatic brainstem cavernomas (medulla, pons, or midbrain) and outcome after surgical resection. We retrospectively analyzed clinical data of all patients who presented to our institution with symptomatic brainstem cavernomas between 1995 and 2007 (n = 44). After a first neurological event, the median event-free interval was 2 years, with an annual event rate of 42%. After a second neurological event (new neurological deficit or significant worsening of the previous deficit), the median event-free interval was only 5 months, with a monthly event rate of 8%. After an observation period of up to 8 years, all patients ultimately underwent surgery. In 95% of the patients, surgery successfully prevented further events during a median follow-up period of 11 months (1 month-7 years; P < 0.001). The postoperative event rate was 5% per year in the first 2 years and 0% thereafter. In the multivariate analysis, only the preoperative modified Rankin scale score was predictive of the surgical outcome (odds ratio, 36.7; P = 0.015). The conditions of 2 patients (5%) were clinically worse compared with their preoperative conditions during the 1-year follow-up period; in one of these patients, this was caused by recurrent events. There was no mortality. The event rate of symptomatic lesions seems to be high, particularly after recurrent events. Surgical morbidity can be low. Timely and complete surgical resection is recommended for symptomatic brainstem cavernomas to prevent patients' functional decline owing to recurrent events.

A brainstem cavernoma demonstrating a dramatic, spontaneous decrease in size during follow-up: case report and review of the literature

Background Many reports have demonstrated a worse prognosis for patients whose cavernomas were subtotally removed than for those whose cavernomas were not surgically treated. Therefore, it is better not to touch the cavernoma if a surgeon is not prepared to totally remove it. This report describes a large brainstem cavernoma showing a spontaneous, dramatic reduction in size after removal of only the biopsy specimen of the lesion. Case Description A 42-year-old woman experienced facial numbness, diplopia, and ataxia. A magnetic resonance (MR) study revealed a pontine cavernoma with hemorrhage. Two weeks later, recurrence of the patient's symptoms and consciousness disturbance were noted. An MR study revealed massive hemorrhage from the cavernoma with a ventricle dilatation. An operation on the lesion was conducted 3 months after the initial hemorrhage. However, the operation was aborted when an exploration of the lesion showed a tight adhesion between the lesion and the pons. Removal of only a biopsy specimen and evacuation of the suckable hematoma were done. No neurologic recovery and no decrease in the size of the cavernoma were detected postoperatively. Her family did not wish for further treatments. She was in a bedridden state with severe brainstem dysfunction when she was transferred to a local hospital. Sixteen months after the surgery, her consciousness was clear, and MR imaging confirmed a marked reduction in the size of the cavernoma. Conclusion A dramatic, spontaneous decrease in size does occur even in the case of a large brainstem cavernoma showing hemorrhages. Conservative therapy may be one of the treatment options for the symptomatic brainstem cavernoma.

Surgical removal of brain stem cavernous malformations: surgical indications, technical considerations, and results

Objectives: This study was undertaken to review the indications for surgical treatment of brain stem cavernomas and to develop strategies to minimise the complications of surgery. Patients and results: Twelve...

Surgical management of brain-stem cavernomas.

We present a series of seven patients who were operated on for symptomatic brain-stem cavernomas. The following approaches were used: medial suboccipital (N = 4), lateral suboccipital (N = 1), subtemporal-transtentorial (N = 1), and frontal transcortical-transventricular-subchorioidal-trans velum interpositum (N = 1). Intraoperative motor (N = 4) and somatosensory (N = 1) evoked potential monitoring revealed temporary changes in 3 patients. Immediately postoperatively, the following additional deficits were observed in 6 patients: oculomotor nerve paresis (N = 2), abducens nerve paresis (N = 3), facial nerve paresis (N = 2), deafness (N = 1), and increased ataxia (N = 3). One patient died due to septic complications not related to surgery. After a mean observation time of 2 years, 2 patients had improved, 3 were unchanged, and 1 patient deteriorated as compared to his preoperative status. In conclusion, surgical treatment of brain-stem cavernomas, although carrying a significant risk of temporary neurological deterioration is recommended in symptomatic patients in whom the cavernoma seems to reach the surface of the brain-stem. Intraoperative functional topographic mapping and monitoring have proven useful tools lowering the surgical risks in these patients.