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Surgical management of symptomatic brain stem cavernoma in a developing country: technical difficulties and outcome

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Abstract

Brain stem cavernomas (BSCs) are angiographically occult vascular malformations in an intricate location. Surgical excision of symptomatic BSCs represents a neurosurgical challenge especially in developing countries. We reviewed the clinical data and surgical outcome of 24 consecutive cases surgically treated for brain stem cavernoma at the Neurosurgery Department, Alexandria University, between 2006 and 2014. All patients were followed up for at least 12 months after surgery and the mean follow-up period was 45 months. All patients suffered from at least two clinically significant hemorrhagic episodes before surgery. There were 10 males and 14 females. The mean age was 34 years (range 12 to 58 years). Fourteen cases had pontine cavernomas, 7 cases had midbrain cavernomas, and in 3 cases, the lesion was found in the medulla oblongata. The most commonly used approach in this series was the midline suboccipital approach with or without telovelar exposure (9 cases). There was a single postoperative mortality in this series due to pneumonia. Fourteen cases (58.3 %) showed initial worsening of their preoperative neurological status, most of which was transient and only three patients had permanent new deficits and one case had a permanent worsening of her preoperatively existing hemiparesis. There was neither immediate nor long-term rebleeding in any of our cases. In spite of the significant associated risks, surgery for BSCs in properly selected patients can have favorable outcomes in most cases. Surgery markedly improves the risk of rebleeding and should be considered in patients with accessible lesions.

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Authors and Affiliations

  1. Neurosurgery Department, Alexandria Main University Hospital, Raml Station, 21131, Alexandria, Egypt

    Ahmed Farhoud & Hisham Aboul-Enein

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  1. Ahmed Farhoud
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  2. Hisham Aboul-Enein
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Correspondence to Ahmed Farhoud.

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Comments

Helmut Bertalanffy, Hannover, Germany

This important and timely publication furnishes evidence of a new quality of neurosurgical management in Egypt. The authors of this article eloquently demonstrate that intrinsic surgery within the brainstem is not only feasible in their country but is possible even with excellent results. Regrettably, too many neurologists, neurosurgeons, or radiooncologists are still unaware about this possibility. As shown by doctors Farhoud and Aboul-Enein, brainstem surgery requires not only microsurgical skillfulness but also appropriate technical equipment and—most importantly—the clinical know-how for patient selection, adequate indication for surgery, and correct choice of the surgical approach including the precise entry zone into the brainstem. All these prerequisites are now available in Egypt as I could convince myself on many occasions while visiting this country. More than a decade ago, both authors have been my pupils, studying with me in Germany for a significant period of time. Over the past years, they have become experienced and talented neurosurgeons, able to safely treat patients even with difficult brainstem lesions. I wish to commend both authors for their achievements and the good results in this remarkable patient series.

I also wish to encourage more colleagues in Egypt and elsewhere to take notice of this progress in the microsurgical management of brainstem lesions in a developing country and to consider direct brainstem surgery in selected cases or to send their patients with brainstem lesions to experts in the field such as doctors Ahmed Farhoud and Hisham Aboul-Enein.

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Farhoud, A., Aboul-Enein, H. Surgical management of symptomatic brain stem cavernoma in a developing country: technical difficulties and outcome. Neurosurg Rev 39, 467–473 (2016). https://doi.org/10.1007/s10143-016-0712-0

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