Intraoperative rupture of brainstem cavernous malformation

Leković, Gregory P.; Gonzalez, L. Fernando; Khurana, Vini G.; Spetzler, Robert F.

doi:10.3171/foc.2006.21.1.15

Cited by 6 publications

(7 citation statements)

References 25 publications

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“…Sacrifice of the DVA will invariably lead to a venous infarct with disastrous clinical sequelae. 32,46,50,53 Developmental venous anomalies are usually absent in patients with familial CMs. 44 …”

Section: General Clinical and Surgical Considerationsmentioning

confidence: 99%

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Giliberto

Lanzino²,

Diehn

et al. 2010

FOC

112

103

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Symptomatic brainstem cavernous malformations carry a high risk of permanent neurological deficit related to recurrent hemorrhage, which justifies aggressive management. Detailed knowledge of the microscopic and surface anatomy is important for understanding the clinical presentation, predicting possible surgical complications, and formulating an adequate surgical plan. In this article the authors review and illustrate the surgical and microscopic anatomy of the brainstem, provide anatomoclinical correlations, and illustrate a few clinical cases of cavernous malformations in the most common brainstem areas.

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Section: General Clinical and Surgical Considerationsmentioning

confidence: 99%

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Giliberto

Lanzino²,

Diehn

et al. 2010

FOC

112

103

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“…Although the risk of postoperative rehemorrhage following surgery was reduced to 2.0% per year in one series, high rates of new postsurgical deficits are routinely reported. 21,25,35 Despite advances in the microsurgical techniques, in a large single-center series of 260 adult patients with surgically treated brainstem CMs, 53% of the patients developed new or worsening neurological symptoms postoperatively; these neurological deficits were permanent in 36%. 4 This is not surprising in light of the eloquent perilesional white matter.…”

mentioning

confidence: 99%

“…Resection is fraught with significant rates of permanent neurological deterioration, including for brainstem CMs reaching the pial surface. 4,25 The increased surgical morbidity is partly due to uncertainty regarding the precise location of the affected white matter tracts. Preoperative identification of these tracts in their accurate spatial orientation may lead to a safer surgical corridor to reduce any potential morbidity.…”

mentioning

confidence: 99%

“…The estimated bleeding and rebleeding rates for brainstem CMs range from 0.5% to 6% and 5% to 60% per patient-year, respectively. 10,25,26,35 The management of brainstem CMs remains challenging due to a high degree of potential morbidity and mortality with and without treatment and specifically due to the eloquence of the perilesional anatomy. Resection is fraught with significant rates of permanent neurological deterioration, including for brainstem CMs reaching the pial surface.…”

mentioning

confidence: 99%

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Longitudinal evaluation of corticospinal tract in patients with resected brainstem cavernous malformations using high-definition fiber tractography and diffusion connectometry analysis: preliminary experience

Faraji¹,

Kumar²,

Jarbo

et al. 2015

JNS

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abbreviatioNs ADL = activities of daily living; CC = corpus callosum; CM = cavernous malformation; CN = cranial nerve; CST = corticospinal tract; DSI = diffusion spectrum imaging; DTI = diffusion tensor imaging; FDR = false discovery rate; HDFT = high-definition fiber tractography; ICH = intracerebral hemorrhage; QA = quantitative anisotropy; ROI = region of interest; SRS = stereotactic radiosurgery. obJect Brainstem cavernous malformations (CMs) are challenging due to a higher symptomatic hemorrhage rate and potential morbidity associated with their resection. The authors aimed to preoperatively define the relationship of CMs to the perilesional corticospinal tracts (CSTs) by obtaining qualitative and quantitative data using high-definition fiber tractography. These data were examined postoperatively by using longitudinal scans and in relation to patients' symptomatology. The extent of involvement of the CST was further evaluated longitudinally using the automated "diffusion connectometry" analysis. methods Fiber tractography was performed with DSI Studio using a quantitative anisotropy (QA)-based generalized deterministic tracking algorithm. Qualitatively, CST was classified as being "disrupted" and/or "displaced." Quantitative analysis involved obtaining mean QA values for the CST and its perilesional and nonperilesional segments. The contralateral CST was used for comparison. Diffusion connectometry analysis included comparison of patients' data with a template from 90 normal subjects. results Three patients (mean age 22 years) with symptomatic pontomesencephalic hemorrhagic CMs and varying degrees of hemiparesis were identified. The mean follow-up period was 37.3 months. Qualitatively, CST was partially disrupted and displaced in all. Direction of the displacement was different in each case and progressively improved corresponding with the patient's neurological status. No patient experienced neurological decline related to the resection. The perilesional mean QA percentage decreases supported tract disruption and decreased further over the follow-up period (Case 1, 26%-49%; Case 2, 35%-66%; and Case 3, 63%-78%). Diffusion connectometry demonstrated rostrocaudal involvement of the CST consistent with the quantitative data. coNclusioNs Hemorrhagic brainstem CMs can disrupt and displace perilesional white matter tracts with the latter occurring in unpredictable directions. This requires the use of tractography to accurately define their orientation to optimize surgical entry point, minimize morbidity, and enhance neurological outcomes. Observed anisotropy decreases in the perilesional segments are consistent with neural injury following hemorrhagic insults. A model using these values in different CST segments can be used to longitudinally monitor its craniocaudal integrity. Diffusion connectometry is a complementary approach providing longitudinal information on the rostrocaudal involvement of the CST.

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“…There may be hyalinization, thrombosis with varying degrees of organization, calcification, cysts, or cholesterol crystals (11) . Cavernomas had been studied for more than 150 years, but only when MRI was introduced as a diagnostic tool, their natural history and/or indication for surgery were truly studied (12) .…”

Section: Discussionmentioning

confidence: 99%

Brainstem cavernomas: a surgical challenge

Aguiar

Zicarelli

Isolan

et al. 2012

Einstein (São Paulo)

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Objective: The authors show their experience with brainstem cavernomas, comparing their data with the ones of a literature review. Methods: From 1998 to 2009, 13 patients harboring brainstem cavernomas underwent surgical resection. All plain films, medical records and images were reviewed in order to sample the most important data regarding epidemiology, clinical picture, radiological findings and surgical outcomes, as well as main complications. Results: The mean age was 42.4 years (ranging from 19 to 70). No predominant gender: male-to-female ratio, 6:7. Pontine cases were more frequent. Magnetic resonance imaging was used as the imaging method to diagnose cavernomas in all cases. The mean follow-up was 71.3 months (range of 1 to 138 months). Clinical presentation was a single cranial nerve deficit, VIII paresis, tinnitus and hearing loss (69.2%). All 13 patients underwent resection of the symptomatic brainstem cavernoma. Complete removal was accomplished in 11 patients. Morbidity and mortality were 15.3 and 7.6%, respectively. Conclusions: Cavernomas can be resected safely with optimal surgical approach (feasible entry zone) and microsurgical techniques, and the goal is to remove all lesions with no cranial nerves impairment. Keywords

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Intraoperative rupture of brainstem cavernous malformation

Cited by 6 publications

References 25 publications

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Brainstem cavernous malformations: anatomical, clinical, and surgical considerations

Longitudinal evaluation of corticospinal tract in patients with resected brainstem cavernous malformations using high-definition fiber tractography and diffusion connectometry analysis: preliminary experience

Brainstem cavernomas: a surgical challenge

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