Download PDF
CC BY-NC-ND 4.0 · Asian J Neurosurg 2019; 14(01): 15-27
DOI: 10.4103/ajns.AJNS_158_18
Review Article

Timing of surgery and surgical strategies in symptomatic brainstem cavernomas: Review of the literature

Niranjana Rajagopal
Department of Neurosurgery, Sathya Sai Institute of Higher Medical Science, Bengaluru, Karnataka
,
Tsukasa Kawase
1   Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya
,
Ameen Mohammad
2   Department of Neurosurgery, Aayush Hospital, Vijayawada, Andhra Pradesh
,
Liew Seng
3   Department of Neurosurgery, Sungai Buloh Hospital, Selangor
,
Yasuhiro Yamada
1   Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya
,
Yoko Kato
1   Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

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.

Key-words:

Brainstem cavernomas - microsurgery - safe entry zones - surgical approaches

Financial support and sponsorship

Nil.




Publication History

Article published online:
09 September 2022

© 2019. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Xie MG, Li D, Guo FZ, Zhang LW, Zhang JT, Wu Z, et al. Brainstem cavernous malformations: Surgical indications based on natural history and surgical outcomes. World Neurosurg 2018;110:55-63.
  • 2 Gross BA, Du R. Hemorrhage from cerebral cavernous malformations: A systematic pooled analysis. J Neurosurg 2017;126:1079-87.
  • 3 Scavo CG, Roperto R, Cacciotti G, Mastronardi L. Cystic progression of a cavernous malformation at the level of the trigeminal root entry zone presenting with sudden onset of trigeminal neuralgia. J Craniofac Surg 2018;1.
  • 4 Taslimi S, Modabbernia A, Amin-Hanjani S, Barker FG 2nd, Macdonald RL. Natural history of cavernous malformation: Systematic review and meta-analysis of 25 studies. Neurology 2016;86:1984-91.
  • 5 Arauz A, Patiño-Rodriguez HM, Chavarria-Medina M, Becerril M, Longo GM, Nathal E, et al. Rebleeding and outcome in patients with symptomatic brain stem cavernomas. Cerebrovasc Dis 2017;43:283-9.
  • 6 Farhoud A, Aboul-Enein H. Surgical management of symptomatic brain stem cavernoma in a developing country: Technical difficulties and outcome. Neurosurg Rev 2016;39:467-73.
  • 7 Ren Y, Li J, Tao C, Zheng J, Zhang S, Xiao A, et al. Surgical treatment of cavernous malformations involving the midbrain: A Single-center case series of 34 patients. World Neurosurg 2017;107:753-63.
  • 8 Garcia RM, Ivan ME, Lawton MT. Brainstem cavernous malformations: Surgical results in 104 patients and a proposed grading system to predict neurological outcomes. Neurosurgery 2015;76:265-77.
  • 9 Abla AA, Lekovic GP, Garrett M, Wilson DA, Nakaji P, Bristol R, et al. Cavernous malformations of the brainstem presenting in childhood: Surgical experience in 40 patients. Neurosurgery 2010;67:1589-98.
  • 10 Petr O, Lanzino G. Brainstem cavernous malformations. J Neurosurg Sci 2015;59:271-82.
  • 11 Li D, Yang Y, Hao SY, Wang L, Tang J, Xiao XR, et al. Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations. J Neurosurg 2013;119:996-1008.
  • 12 Abla AA, Lekovic GP, Turner JD, de Oliveira JG, Porter R, Spetzler RF, et al. Advances in the treatment and outcome of brainstem cavernous malformation surgery: A single-center case series of 300 surgically treated patients. Neurosurgery 2011;68:403-14.
  • 13 Giliberto G, Lanzino DJ, Diehn FE, Factor D, Flemming KD, Lanzino G, et al. Brainstem cavernous malformations: Anatomical, clinical, and surgical considerations. Neurosurg Focus 2010;29:E9.
  • 14 Negoto T, Terachi S, Baba Y, Yamashita S, Kuramoto T, Morioka M. Symptomatic brainstem cavernoma of elderly patients: Timing and strategy of surgical treatment. Two case reports and review of the literature. World Neurosurg 2018;111:227-34.
  • 15 Zaidi HA, Mooney MA, Levitt MR, Dru AB, Abla AA, Spetzler RF, et al. Impact of timing of intervention among 397 consecutively treated brainstem cavernous malformations. Neurosurgery 2017;81:620-6.
  • 16 Al-Shahi Salman R, Hall JM, Horne MA, Moultrie F, Josephson CB, Bhattacharya JJ, et al. Untreated clinical course of cerebral cavernous malformations: A prospective, population-based cohort study. Lancet Neurol 2012;11:217-24.
  • 17 Horne MA, Flemming KD, Su IC, Stapf C, Jeon JP, Li D, et al. Clinical course of untreated cerebral cavernous malformations: A meta-analysis of individual patient data. Lancet Neurol 2016;15:166-73.
  • 18 Al-Shahi Salman R, Berg MJ, Morrison L, Awad IA, Angioma Alliance Scientific Advisory Board. Hemorrhage from cavernous malformations of the brain: Definition and reporting standards. Angioma alliance scientific advisory board. Stroke 2008;39:3222-30.
  • 19 Starke RM. Do brainstem cavernous malformations have a higher rate of hemorrhage? Expert Rev Neurother 2015;15:1109-11.
  • 20 Ruggeri AG, Donnarumma P, Pichierri A, Delfini R. Two cystic cavernous angiomas after radiotherapy for atypical meningioma in adult woman: Case report and literature review. J Korean Neurosurg Soc 2014;55:40-2.
  • 21 Li D, Hao SY, Jia GJ, Wu Z, Zhang LW, Zhang JT, et al. Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations. J Neurosurg 2014;121:32-41.
  • 22 Li D, Hao SY, Tang J, Xiao XR, Jia GJ, Wu Z, et al. Surgical management of pediatric brainstem cavernous malformations. J Neurosurg Pediatr 2014;13:484-502.
  • 23 Hu P, Liang J, Bao Y, Li M, Ling F. The pterional transsylvian transtentorial approach to ventrolateral pontine cavernomas: Indications and techniques. World Neurosurg 2014;82:1276-82.
  • 24 Huang AP, Chen JS, Yang CC, Wang KC, Yang SH, Lai DM, et al. Brain stem cavernous malformations. J Clin Neurosci 2010;17:74-9.
  • 25 Porter RW, Detwiler PW, Spetzler RF, Lawton MT, Baskin JJ, Derksen PT, et al. Cavernous malformations of the brainstem: Experience with 100 patients. J Neurosurg 1999;90:50-8.
  • 26 Wang CC, Liu A, Zhang JT, Sun B, Zhao YL. Surgical management of brain-stem cavernous malformations: Report of 137 cases. Surg Neurol 2003;59:444-54.
  • 27 Porter PJ, Willinsky RA, Harper W, Wallace MC. Cerebral cavernous malformations: Natural history and prognosis after clinical deterioration with or without hemorrhage. J Neurosurg 1997;87:190-7.
  • 28 Gross BA, Batjer HH, Awad IA, Bendok BR. Brainstem cavernous malformations. Neurosurgery 2009;64:E805-18.
  • 29 Kupersmith MJ, Kalish H, Epstein F, Yu G, Berenstein A, Woo H, et al. Natural history of brainstem cavernous malformations. Neurosurgery 2001;48:47-53.
  • 30 Gross BA, Batjer HH, Awad IA, Bendok BR, Du R. Brainstem cavernous malformations: 1390 surgical cases from the literature. World Neurosurg 2013;80:89-93.
  • 31 Dukatz T, Sarnthein J, Sitter H, Bozinov O, Benes L, Sure U, et al. Quality of life after brainstem cavernoma surgery in 71 patients. Neurosurgery 2011;69:689-95.
  • 32 Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to brainstem cavernous malformations. Neurosurg Focus 2010;29:E8.
  • 33 Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: A series of 176 patients. Neurosurgery 2013;72:573-89.
  • 34 Chen L, Zhao Y, Zhou L, Zhu W, Pan Z, Mao Y, et al. Surgical strategies in treating brainstem cavernous malformations. Neurosurgery 2011;68:609-20.
  • 35 Ferroli P, Sinisi M, Franzini A, Giombini S, Solero CL, Broggi G, et al. Brainstem cavernomas: Long-term results of microsurgical resection in 52 patients. Neurosurgery 2005;56:1203-12.
  • 36 Zhang S, Li H, Liu W, Hui X, You C. Surgical treatment of hemorrhagic brainstem cavernous malformations. Neurol India 2016;64:1210-9.
  • 37 Perrini P, Lanzino G. The association of venous developmental anomalies and cavernous malformations: Pathophysiological, diagnostic, and surgical considerations. Neurosurg Focus 2006;21:e5.
  • 38 Knerlich-Lukoschus F, Steinbok P, Dunham C, Cochrane DD. Cerebellar cavernous malformation in pediatric patients: Defining clinical, neuroimaging, and therapeutic characteristics. J Neurosurg Pediatr 2015;16:256-66.
  • 39 Zhang P, Liu L, Cao Y, Wang S, Zhao J. Cerebellar cavernous malformations with and without associated developmental venous anomalies. BMC Neurol 2013;13:134.
  • 40 Cavalcanti DD, Preul MC, Kalani MY, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg 2016;124:1359-76.
  • 41 Frischer JM, Gatterbauer B, Holzer S, Stavrou I, Gruber A, Novak K, et al. Microsurgery and radiosurgery for brainstem cavernomas: Effective and complementary treatment options. World Neurosurg 2014;81:520-8.
  • 42 Garrett M, Spetzler RF. Surgical treatment of brainstem cavernous malformations. Surg Neurol 2009;72 Suppl 2:S3-9.
  • 43 Ohue S, Fukushima T, Kumon Y, Ohnishi T, Friedman AH. Surgical management of brainstem cavernomas: Selection of approaches and microsurgical techniques. Neurosurg Rev 2010;33:315-22.
  • 44 Li H, Ju Y, Cai BW, Chen J, You C, Hui XH, et al. Experience of microsurgical treatment of brainstem cavernomas: Report of 37 cases. Neurol India 2009;57:269-73.
  • 45 Ramina R, Mattei TA, de Aguiar PH, Meneses MS, Ferraz VR, Aires R, et al. Surgical management of brainstem cavernous malformations. Neurol Sci 2011;32:1013-28.
  • 46 Lu XY, Sun H, Xu JG, Li QY. Stereotactic radiosurgery of brainstem cavernous malformations: A systematic review and meta-analysis. J Neurosurg 2014;120:982-7.
  • 47 Chan AC, Li DY, Berg MJ, Whitehead KJ. Recent insights into cerebral cavernous malformations: Animal models of CCM and the human phenotype. FEBS J 2010;277:1076-83.
  • 48 Li DY, Whitehead KJ. Evaluating strategies for the treatment of cerebral cavernous malformations. Stroke 2010;41:S92-4.
  • 49 Faurobert E, Albiges-Rizo C. Recent insights into cerebral cavernous malformations: A complex jigsaw puzzle under construction. FEBS J 2010;277:1084-96.
  • 50 Reinhard M, Schuchardt F, Meckel S, Heinz J, Felbor U, Sure U, et al. Propranolol stops progressive multiple cerebral cavernoma in an adult patient. J Neurol Sci 2016;367:15-7.
  • 51 Zabramski JM, Kalani MY, Filippidis AS, Spetzler RF. Propranolol treatment of cavernous malformations with symptomatic hemorrhage. World Neurosurg 2016;88:631-9.