Symptomatic Brainstem Cavernoma of Elderly Patients: Timing and Strategy of Surgical Treatment. Two Case Reports and Review of the Literature

Abstract

Radical resection of the cavernoma with severe symptoms might be recommended in elderly patients, especially in those with multiple rebleeding events. From the viewpoint of surgery, we consider the subacute phase the optimal time to remove cavernomas in elderly hemorrhagic patients. However, multiple rebleeding events might exacerbate the neurologic deficit. Therefore, the subacute phase from the first or second rebleeding might be the best time for the surgical resection. At surgical intervention, preservation of the surrounding brain should be prioritized over complete removal of the cavernoma and hematoma.

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

“…The true natural history of these familiar lesions is yet unclear despite so many studies on the topic. [14] They are low flow vascular malformations. [3] The most common location of CMs in the brain stem is the pons followed by the midbrain and medulla.…”

“…Annual rates of hemorrhage range from 2.3% to 13.6% and rebleeding rates vary between 5% and 21.5% in various studies. [21014] There is a significant range in the variability in the annual hemorrhagic rate from 15% to 60.9% as quoted by various authors such as Taslimi et al .,[4] Horne et al ., and others. [151617] However, there are various confounding factors that could have led to this large variability, thus making it difficult to bank on any result till date.…”

“…[4791022262832] In the geriatric population, intervention after a symptomatic bleed is essential as the elderly are less tolerant to the functional damage, thus compromising on the quality of life with worse outcomes. [14] Deep-seated lesions, notably those which are inaccessible to the safe entry zones, carry a higher risk of immediate and long-term morbidity,[35] where only some have had impressive results after the removal of such catastrophic lesions. [126] It is safer to have a “wait and watch policy” till further bleeding episodes in these patients as that might make the lesion more amenable to surgery by reaching closer to a pial surface.…”

“…[15] who have large series (>100 patients) recommend intervention after 4 weeks but before 8 weeks of bleed, coz a further delay in surgery as there is retraction and organization of the hematoma along with gliosis, hyaline degeneration, and calcifications leading to tight adherence between the CM and the surrounding parenchyma, making the dissection plane obscure thus increasing the likelihood of mechanical trauma from surgical manipulation. [7810131421222633]…”

Predictive factors of postoperative infection-related complications in adult patients with cerebral cavernous malformations

“…Cerebral cavernous malformation (CCM) is a benign cerebral vascular hamartoma commonly seem in neurosurgery. For CCM patient presenting with hemorrhage, having focal neurological malfunction or epilepsy, surgery is a routine treatment method [1][2][3][4][5] . In recent decades, advances in surgical techniques, postoperative care, and treatment strategies have improved clinical outcomes of CCM patients.…”