Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

Abstract

ObjectiveSurgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem.Materials and MethodsWe reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated.ResultsA total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%.ConclusionMicroneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.

Identifying potential (re)hemorrhage among sporadic cerebral cavernous malformations using machine learning

“…Researchers identified prior hemorrhage as a major risk factor for subsequent hemorrhage 7 , 9 , 41 – 43 . Localized in deep regions of the brain, brainstem CCM and thalamic CCM took up approximately one-third 44 and it was found that CCM lesions at the brainstem increased hemorrhage rate 12 , 45 – 48 .…”

Deep Ganglionic Intracerebral Hemorrhage Due to Cavernous Malformation Mimicking Hypertensive Hemorrhage: A Report of Two Cases

“…Therefore, we must always consider vascular malformations, including CMs, in the differential diagnosis of patients with ICH regardless of the volume of the hematoma. When intraoperative findings suggest the presence of CM, complete surgical removal should be the goal of treatment to prevent postoperative hemorrhage because residual CMs have been reported to increase the risk of re-hemorrhage [24][25][26].…”

A Case of Cavernous Malformation of the Midbrain Removed via an Interhemispheric Transcallosal Subchoroidal Approach

“…12,13) This approach has two major advantages: first, craniotomy is simple and quick, and the midline approach avoids damage to the brain surface. 12,14) Second, the final surgical view is good, and the entire floor of the third ventricle can be observed, even if the lesion extends into the thalamus. 12,14) Conversely, two major points were observed in this approach: first, disconnection syndrome may occur with callosotomy, and callosotomy should be performed at !…”

“…12,14) Second, the final surgical view is good, and the entire floor of the third ventricle can be observed, even if the lesion extends into the thalamus. 12,14) Conversely, two major points were observed in this approach: first, disconnection syndrome may occur with callosotomy, and callosotomy should be performed at ! 2 cm to prevent this disorder.…”