Petrosal approaches to brainstem cavernous malformations

Gross, Bradley A.; Dunn, Ian F.; Du, Rose; Al‐Mefty, Ossama

doi:10.3171/2012.6.focus12110

Cited by 33 publications

(20 citation statements)

References 55 publications

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“…Other predictors included surgery within 1 year of seizure onset, CM size less than 1.5 cm, solitary CMs, partial seizures only and medical control of the seizures preoperatively. Overall 1.6-3.1% [10,12,14] Incidental CM 0.08-0.2% [5,32] Any unruptured CM 0.3-0.6% [10,12,33,34] Ruptured CM 4.5-22.9% [5,10,12,[33][34][35] Ruptured, within first year 14-18% Resection of eloquent CMs is a subject of significant neurosurgical interest as supratentorial deep CMs and brainstem CMs require both creative and meticulous surgical approaches and technique to allow for successful resection with minimal operative morbidity [18][19][20][21][22][23][24]52,53,[55][56][57][58]. Most of these lesions would be considered 'grade III' CMs in the scheme of Kivelev and colleagues.…”

Section: Surgical Excisionmentioning

confidence: 99%

Cerebral cavernous malformations: natural history and clinical management

Gross¹,

2015

Expert Review of Neurotherapeutics

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Cavernous malformations (CMs) are angiographically-occult clusters of dilated sinusoidal channels that may present clinically with seizures, focal neurological deficits and/or hemorrhage. Across natural history studies, the annual hemorrhage rate ranged from 1.6-3.1% per patient-year, decreasing to 0.08-0.2% per patient-year for incidental CMs and to 0.3-0.6% for the collective group of unruptured CMs. Prior hemorrhage is a significant risk factor for subsequent CM hemorrhage. Hemorrhage clustering, particularly within the first 2 years, is an established phenomenon that may confound results of natural history studies evaluating the rate of rehemorrhage. Indeed, rehemorrhage rates for hemorrhagic CMs range from 4.5-22.9% in the literature. Surgical resection is the gold standard treatment for surgically-accessible, symptomatic CMs. Incidental CMs or minimally symptomatic, surgically inaccessible eloquent lesions may be considered for observation. Stereotactic radiosurgery is a controversial treatment approach of consideration only for cases of highly aggressive, surgically inaccessible CMs.

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Section: Surgical Excisionmentioning

confidence: 99%

Cerebral cavernous malformations: natural history and clinical management

Gross¹,

2015

Expert Review of Neurotherapeutics

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“…4,5,10,[29][30][31]46,53,59,61 A lateral trajectory was preferred for lesions in the pons. 4,19,33,35,46,67 Electrophysiological monitoring of the cranial nerves (according to lesion location), somatosensory evoked potentials, motor evoked potentials, and brainstem auditory evoked potentials was performed routinely. Intraoperative neuronavigation was used in a few cases.…”

Section: Surgical Strategymentioning

confidence: 99%

Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations

Yang

Hao

et al. 2013

JNS

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Object The aim of this study was to evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up. Methods The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined. Results The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter. Conclusions Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.

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“…Adding to the difficulty is the need to preserve the patient's hearing in order to maintain quality of life; a previous comprehensive review reported that 12% of patients who received an anterior petrosectomy due to brainstem cavernous malformations experienced perioperative hear- ing loss. 6 The incidence of hearing loss may be increased in proportion to the location of the lesion, size of the lesion, and the level of difficulty of the surgery.…”

Section: Resultsmentioning

confidence: 99%

“…The extent of petrosectomy has been widened from the time of introduction of this approach in the neurosurgical field until recently, and this approach is known to be effective for accessing ventral mid-to upper pontine lesions in particular. 1,[4][5][6]9 In fact, when performing the anterior petrosal approach in the narrow space of the parallelogram-shaped anterior surface of the petrous bone, which is bounded by V3, the GSPN, the superior semicircular canal, and the petrous ridge, only approximately 3 cm 2 may not present a straightforward procedure with a manageable learning curve. Adding to the difficulty is the need to preserve the patient's hearing in order to maintain quality of life; a previous comprehensive review reported that 12% of patients who received an anterior petrosectomy due to brainstem cavernous malformations experienced perioperative hear- ing loss.…”

Section: Resultsmentioning

confidence: 99%

Cochlear line: a novel landmark for hearing preservation using the anterior petrosal approach

Kim¹,

Lee

Kim

et al. 2015

JNS

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T he anterior petrosal approach introduced by Kawase et al. was designed to enable wider and closer surgical exposure for treatment of ventral brainstem lesions. 1 The technique provides easy access to large sphenopetroclival meningiomas, dumbbell-shaped trigeminal schwannomas, and giant acoustic neuromas located in front of the brainstem and basilar trunk aneurysms. 5,7,9 The advantage of this technique is a lower possibility of postoperative hearing loss, vestibulopathy, and facial paresis in comparison with the transcochlear approach and/ or combined middle fossa posterior approach, which both provide similar surgical fields. 1To perform the anterior petrosal approach more safely, the use of possible anatomical landmarks, including the maxillary branch of the trigeminal nerve (V3), gasserian ganglion, greater superficial petrosal nerve (GSPN), petrous internal carotid artery (ICA), cochlea, geniculate ganglion, dura mater of the internal acoustic canal (IAC), labyrinthine portion of the facial nerve, vestibule, and superior semicircular canal can also be put to good use. Of these, the cochlea is well known to be located anterior to the fundus of the IAC, inferior to the geniculate ganglion. This relationship is frequently used as an anatomical landmark. In addition, the difference in bone density between the petrous bone and the cochlea can also be another clue for determining the location of the cochlea. 4 However, surgeons may be faced with unexpected difficulty in applying these concepts in real surgical fields. In this study, based on dissection results in 5 fresh cadavers, we aimed to develop a practical landmark for the safe and easy identification of the cochlea when applying the anterior petrosal approach. MethodsThis study was approved by the institutional review board of Eulji University. Five fresh cadaver heads were dissected in the microdissection laboratory.abbreviatioNs GSPN = greater superficial petrosal nerve; IAC = internal acoustic canal; ICA = internal carotid artery; V3 = maxillary branch of the trigeminal nerve. obJect The goal of this study was to develop a practical landmark for the safe and easy identification of the cochlea when performing anterior petrosectomy based on cadaver dissection results. Methods The cochlear line was defined as the line drawn from the crossing point between the greater superficial petrosal nerve (GSPN) and the petrous internal carotid artery to the line drawn over the apex of the superior circumference of the dura of the internal auditory canal at a right angle. The validity of the cochlear line marking the anteromedial perimeter of the cochlea at the angle of the GSPN and the internal acoustic canal as a practical landmark were evaluated using 5 cadaver heads. results The mean distance (± SD) measured from the cochlear line to the margin of the cochlear cavity was 2.25 ± 0.51 mm (range 1.50-3.00 mm). coNclusioNs Anterior petrosectomy can be performed more efficiently by using the cochlear line as a key landmark to preserve the cochlea.

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Petrosal approaches to brainstem cavernous malformations

Cited by 33 publications

References 55 publications

Cerebral cavernous malformations: natural history and clinical management

Cerebral cavernous malformations: natural history and clinical management

Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations

Cochlear line: a novel landmark for hearing preservation using the anterior petrosal approach

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