Brainstem cavernous malformations: Natural history versus surgical management

Walcott, Brian P.; Choudhri, Omar; Lawton, Michael T.

doi:10.1016/j.jocn.2016.03.021

Cited by 25 publications

(16 citation statements)

References 6 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Eight of the 9 patients treated with open surgical intervention had good pain control, but 1 passed away due to a hemorrhage. This is in line with the morbidity and mortality rate for open operative interventions for brainstem CMs, with reports of a 14–36% complication rate in large series [9, 10]. GKRS, in contrast, is very safe for brainstem pathology, with adverse radiation events occurring in approximately 5% of patients in a series of CM in the brainstem [11, 12].…”

Section: Discussionsupporting

confidence: 55%

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

Pease

Withrow

Ozpinar

et al. 2018

Stereotact Funct Neurosurg

View full text Add to dashboard Cite

Objective: Trigeminal neuralgia (TN) related to a brainstem cavernous malformation (CM) is a rare entity. We present the first radiosurgical management of a patient with TN secondary to a CM. Clinical Presentation: An 80-year-old female presented with a 33-year history of progressively severe TN refractory to medications. Imaging confirmed a solitary CM located at the pontine dorsal root entry zone of cranial nerve 5. Treatment: Stereotactic radiosurgery of the trigeminal nerve was performed using the Leksell gamma knife. A single 4-mm isocenter of radiation was focused on the trigeminal nerve and a maximum dose of 80 Gy (40 Gy at the 50% isodose line) was delivered to the nerve. Results: At 1 year, the patient noted that the severe pain attacks had been reduced by 75%, although a background lingering discomfort persisted. Pain suppression medications had been significantly reduced to lamotrigine 100 mg twice daily. Her preoperative distribution of sensory dysfunction mildly increased. Conclusion: For medically refractory TN related to a CM, radiosurgery of the afferent nerve may ameliorate pain without a major decrease in sensation. The more than 30-year history of pain in our patient may have reduced the chance of more significant pain relief.

show abstract

Section: Discussionsupporting

confidence: 55%

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

Pease

Withrow

Ozpinar

et al. 2018

Stereotact Funct Neurosurg

View full text Add to dashboard Cite

show abstract

“…Brainstem CCMs demonstrate that microsurgical skills are versatile, our surgical approaches can be refined (Supplementary Table 1), our repertoire can be expanded, and our techniques can become increasingly honed. 67 Treatment of brainstem CCMs is a story of success and optimism that seemingly came out of nowhere.…”

Section: Brainstem Microsurgerymentioning

confidence: 99%

The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms

Lawton¹,

Lang²

2019

Journal of Neurosurgery

Self Cite

112

View full text Add to dashboard Cite

Despite the erosion of microsurgical case volume because of advances in endovascular and radiosurgical therapies, indications remain for open resection of pathology and highly technical vascular repairs. Treatment risk, efficacy, and durability make open microsurgery a preferred option for cerebral cavernous malformations, arteriovenous malformations (AVMs), and many aneurysms. In this paper, a 21-year experience with 7348 cases was reviewed to identify trends in microsurgical management. Brainstem cavernous malformations (227 cases), once considered inoperable and managed conservatively, are now resected in increasing numbers through elegant skull base approaches and newly defined safe entry zones, demonstrating that microsurgical techniques can be applied in ways that generate entirely new areas of practice. Despite excellent results with microsurgery for low-grade AVMs, brain AVM management (836 cases) is being challenged by endovascular embolization and radiosurgery, as well as by randomized trials that show superior results with medical management. Reviews of ARUBA-eligible AVM patients treated at high-volume centers have demonstrated that open microsurgery with AVM resection is still better than many new techniques and less invasive approaches that are occlusive or obliterative. Although the volume of open aneurysm surgery is declining (4479 cases), complex aneurysms still require open microsurgery, often with bypass techniques. Intracranial arterial reconstructions with reimplantations, reanastomoses, in situ bypasses, and intracranial interpositional bypasses (third-generation bypasses) augment conventional extracranial-intracranial techniques (first- and second-generation bypasses) and generate innovative bypasses in deep locations, such as for anterior inferior cerebellar artery aneurysms. When conventional combinations of anastomoses and suturing techniques are reshuffled, a fourth generation of bypasses results, with eight new types of bypasses. Type 4A bypasses use in situ suturing techniques within the conventional anastomosis, whereas type 4B bypasses maintain the basic construct of reimplantations or reanastomoses but use an unconventional anastomosis. Bypass surgery (605 cases) demonstrates that open microsurgery will continue to evolve. The best neurosurgeons will be needed to tackle the complex lesions that cannot be managed with other modalities. Becoming an open vascular neurosurgeon will be intensely competitive. The microvascular practice of the future will require subspecialization, collaborative team effort, an academic medical center, regional prominence, and a large catchment population, as well as a health system that funnels patients from hospital networks outside the region. Dexterity and meticulous application of microsurgical technique will remain the fundamental skills of the open vascular neurosurgeon.

show abstract

“…observed an estimated 5-year recurrent hemorrhagic risk of 30.8%, with a 50.7% risk of developing either a recurrent hemorrhage or a new neurological deficit unrelated to hemorrhage. [ 8 ]…”

Section: Discussionmentioning

confidence: 99%

“…[ 1 2 3 4 ] CCMs of the brainstem are particular forms of CMs associated with higher morbidity and mortality rates than other CCMs[ 5 6 ] due to the proximity of the lesion to critical neural structures and to the complex blood supply in the region. [ 7 8 ] Brainstem CMs (BSCMs) account for 15%–18% of intracranial CMs with annual re-hemorrhage rates from 5.1% to as high as 30.8%. With regard to the rarity of BSCMs and the potentially devastating consequences of bleeding, different therapeutic modalities have been proposed: conservative, radiosurgery, or surgery.…”

Section: Introductionmentioning

confidence: 99%

Management and surgical approaches of brainstem cavernous malformations: Our experience and literature review

et al. 2019

View full text Add to dashboard Cite

Introduction:Brainstem cavernous malformations (BSCMs) are clusters of dilated sinusoidal channels. Clinical presentation is characterized by focal neurological deficits and/or hemorrhage. The goal of this study is to analyze surgical indications and approaches in a series of patients with BSCM and review pertinent literature and suggest prognostic factors related to the anatomical, clinical, and surgical data collected.Methods:We retrospectively reviewed the clinical data of 55 patients with BSCM, treated at three centers, from January 2006 to March 2016. We collected anagraphic data, pre and postoperative neurological status, pre and postradiological images, surgical procedures, and follow-up results. We summarized the anatomical, clinical, and surgical aspects of the lesions and identified two large groups based on the chosen approach: lateral and medial. Clinical and radiological results were then compared.Results:The series comprised 55 patients. Hemorrhagic onset was observed in all patients. Suboccipital, retrosigmoid, anterior, subtentorial, subtemporal, transvermian, telovelar, far lateral and trans, and infratentorial approaches were performed. Neurological status improved postoperatively in 34 cases at last follow-up. Five patients showed clinical neurological worsening. Total resection was achieved in 46 cases and, during a mean follow-up of 63.4 months, no recurrence or re-bleeding occurred in those patients. The mean follow-up was 63.9 months. The mean modified Rankin Scale at final follow-up was used to analyze the results and draw our conclusions.Conclusions:A reasonable surgical approach, selection, and gentle handling of the surrounding structures are required to prevent impairment of neurologic function and avoid partial resection.

show abstract

Brainstem cavernous malformations: Natural history versus surgical management

Cited by 25 publications

References 6 publications

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms

Management and surgical approaches of brainstem cavernous malformations: Our experience and literature review

Contact Info

Product

Resources

About