Surgical treatment of brainstem cavernous malformations: an international Delphi consensus

Abstract

OBJECTIVE Indication for surgery in brainstem cavernous malformations (BSCMs) is based on many case series, few comparative studies, and no randomized controlled trials. The objective of this study was to seek consensus about surgical management aspects of BSCM. METHODS A total of 29 experts were invited to participate in a multistep Delphi consensus process on the surgical treatment of BSCM. RESULTS Twenty-two (76%) of 29 experts participated in the consensus. Qualitative analysis (content analysis) of an initial open-ended question survey resulted in 99 statements regarding surgical treatment of BSCM. By using a multistep survey with 100% participation in each round, consensus was reached on 52 (53%) of 99 statements. These were grouped into 4 categories: 1) definitions and reporting standards (7/14, 50%); 2) general and patient-related aspects (11/16, 69%); 3) anatomical-, timing of surgery–, and BSCM-related aspects (22/37, 59%); and 4) clinical situation–based decision-making (12/32, 38%). Among other things, a consensus was reached for surgical timing, handling of associated developmental venous anomalies, handling of postoperative BSCM remnants, assessment of specific anatomical BSCM localizations, and treatment decisions in typical clinical BSCM scenarios. CONCLUSIONS A summary of typical clinical scenarios and a catalog of various BSCM- and patient-related aspects that influence the surgical treatment decision have been defined, rated, and interpreted.

Functional outcome after pediatric cerebral cavernous malformation surgery

“…Our analysis, adjusted to age and sex, identified brainstem localization as a predictor for postoperative deterioration, while non-brainstem localization was not associated with worse outcomes. In accordance with large studies on adult patients and some small-sample pediatric trials, surgery for supratentorial and cerebellar lesions is favorable and safe 2,3,9,14,18,19,29-31 , while removal of brainstem www.nature.com/scientificreports/ CCM remains complex and is associated with a significant risk of postoperative morbidity 12,20,21,32 . In our study, the mean mRS value at admission was 2.0, while in the largest available pediatric brainstem CCM trial of Li and colleagues the authors describe a mean mRS value of 3.0 20 .…”

“…In this population, these lesions represent a considerable source of spontaneous ICH [1][2][3][4] . The value of neurosurgical lesion removal is still discussed controversially, balancing the lifetime risk of spontaneous bleeding events and the risk of surgery-related morbidity 21,22 . Moreover, CCM research in children and adolescents is often limited to small sample size data due to the rarity of the disease.…”

Quality of life and mood assessment in conservatively treated cavernous malformation‐related epilepsy

“…Moreover, literature dealing with quality of life in CRE is exclusively limited to studies investigating the outcome after CCM removal (Dammann, Wrede, et al., 2017 ; Ruan et al., 2015 ; Van Gompel et al., 2010 ). Since treatment is often personalized, particularly in the case of CRE, patients and surgeons often face the difficult question of whether to opt for surgery or continue drug treatment (Dammann et al., 2021 ). Recently published data have highlighted the value of open and minimally invasive surgery for epileptogenic CCM lesions, including pediatric and adult patients (Dammann, Wrede, et al., 2017 ; Kapadia et al., 2021 ; Lee et al., 2017 ; Lin et al., 2018 ; Ozlen et al., 2021 ; Satzer et al., 2020 ; Schuss et al., 2020 ; Willie et al., 2019 ).…”

“…Notably, CCM treatment is still subject to debate. Evidence‐based treatment guidelines are scarce and decision‐making is often limited to clinical experience (Dammann et al., 2021 ; Rosenow et al., 2013 ). Although lesion removal in CRE patients seems justified in selected cases, brain surgery remains a delicate procedure, and noninvasive treatment approaches must be considered, particularly in patients who have minor or no functional impairments (Dammann, Wrede, et al., 2017 ).…”

Endoscope-assisted resection of brainstem cavernous malformations

“…The indication and timing of surgery are still under debate. A large multi-step Delphi consensus on decision-making in the treatment of BSCM has been published recently to improve the quality of evidence [ 12 ]. In case of surgery, gross total resection is considered the gold standard of therapy in this delicate area [ 5 , 36 ].…”