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

Abstract

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.

Commentary: Precuneal Interhemispheric, Transtentorial Approach to a Dorsal Pontine Cavernous Malformation: 2-Dimensional Operative Video

“…On the other hand, lesions extending inferiorly toward the fourth ventricle are better approached with the suboccipital telovelar or transvermian approaches provided that the lesion is surfacing to the floor of fourth ventricle that obviates the need of traversing important structures such as facial colliculus, medial longitudinal fasciculus etc. 1,9,16 Unlike the transvermian approach which transects the inferior vermis thus risking neurological deficit, the telovelar approach uses natural clefts to gain access to the brainstem. 17 Therefore, the telovelar approach has become the preferred approach to gain access to the dorsal pons and floor of the fourth ventricle.…”