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Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques

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Abstract

This study reviewed surgical experience with brainstem cavernomas in an attempt to define optimal surgical approaches and risks associated with surgical management. Clinical courses were retrospectively reviewed for 36 consecutive patients (12 men, 24 women; mean age, 42 years) who underwent microsurgical resection of brainstem cavernomas between 1996 and 2006. Medical records, surgical records, and neuroimaging examinations were evaluated. All 36 patients presented with ≥1 hemorrhage from the cavernomas and preoperatively displayed some neurological symptoms. Surgical approach was midline suboccipital for 16 pontine and/or medullary cavernomas under the floor of the fourth ventricle, retrosigmoid for 10 lateral mesencephalic, pontine, and/or medullary cavernomas, occipital transtentorial for 2 thalamomesencephalic and 3 mesencephalic cavernomas, combined petrosal for 2 pontine cavernomas, and other for 3 cavernomas. Complete resection according to postoperative magnetic resonance imaging was achieved in 33 of 36 patients. No mortality was encountered in this study. New neurological deficit occurred in the early postoperative period for 18 patients, but was transient in 15 of these. Neurological state as of final follow-up was improved in 16 patients (44%), unchanged in 17 (47%), and worsened in 3 (8%) compared with preoperatively. In conclusion, symptomatic brainstem cavernomas should be considered for surgical treatment. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory.

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References

  1. Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T (1995) Natural history of intracranial cavernous malformations. J Neurosurg 83:56–59

    Article  CAS  PubMed  Google Scholar 

  2. Bertalanffy H, Benes L, Miyazawa T, Alberti O, Siegel AM, Sure U (2002) Cerebral cavernomas in the adult. Review of the literature and analysis of 72 surgically treated patients. Neurosurg Rev 25:1–53

    Article  PubMed  Google Scholar 

  3. Bogucki J, Gielecki J, Czernicki Z (1997) The anatomical aspects of a surgical approach through the floor of the fourth ventricle. Acta Neurochir (Wien) 139:1014–1019

    Article  CAS  Google Scholar 

  4. Bouillot P, Dufour H, Roche PH, Lena G, Graziani N, Grisoli F (1996) Angiographically occult vascular malformations of the brain stem. Apropos of 25 cases. Neurochirurgie 42:189–200 (in French)

    CAS  PubMed  Google Scholar 

  5. Brown AP, Thompson BG, Spetzler RF (1996) The two-point method: evaluating brain stem lesions. BNI Quarterly 12:20–24

    Google Scholar 

  6. Dandy W (1928) Venous abnormalities and angiomas of the brain. Arch Surg 17:715–798

    Google Scholar 

  7. Del Curling O, Jr KDL, Jr EAD, Craven TE (1991) An analysis of the natural history of cavernous angiomas. J Neurosurg 75:702–708

    Article  PubMed  Google Scholar 

  8. Fahlbusch R, Strauss C, Huk W (1991) Pontine-mesencephalic cavernomas: indications for surgery and operative results. Acta Neurochir Suppl (Wien) 53:37–41

    CAS  Google Scholar 

  9. Ferroli P, Sinisi M, Franzini A, Giombini S, Solero CL, Broggi G (2005) Brainstem cavernomas: long-term results of microsurgical resection in 52 patients. Neurosurgery 56:1203–1212

    Article  PubMed  Google Scholar 

  10. Fritschi JA, Reulen HJ, Spetzler RF, Zabramski JM (1994) Cavernous malformations of the brain stem. A review of 139 cases. Acta Neurochir (Wien) 130:35–46

    Article  CAS  Google Scholar 

  11. Isamat F, Conesa G (1993) Cavernous angiomas of the brain stem. Neurosurg Clin N Am 4:507–518

    CAS  PubMed  Google Scholar 

  12. Kondziolka D, Lunsford L, Kestle J (1995) The natural history of cerebral cavernous malformations. J Neurosurg 83:820–824

    Article  CAS  PubMed  Google Scholar 

  13. Konovalov AN, Spallone A, Makhmudov UB, Kukhlajeva JA, Ozerova VI (1990) Surgical management of hematomas of the brain stem. J Neurosurg 73:181–186

    Article  CAS  PubMed  Google Scholar 

  14. Kupersmith MJ, Kalish H, Epstein F, Yu G, Berenstein A, Woo H, Jafar J, Mandel G, De Lara F (2001) Natural history of brainstem cavernous malformations. Neurosurgery 48:47–53

    Article  CAS  PubMed  Google Scholar 

  15. Kyoshima K, Kobayashi S, Gibo H, Kuroyanagi T (1993) A study of safe entry zones via the floor of the fourth ventricle for brain-stem lesions. Report of three cases. J Neurosurg 78:987–993

    Article  CAS  PubMed  Google Scholar 

  16. Lewis A, Tew JM Jr (1994) Management of thalamic-basal ganglia and brain-stem vascular malformations. Clin Neurosurg 41:83–111

    CAS  PubMed  Google Scholar 

  17. Mathiesen T, Edner G, Kihlström L (2003) Deep and brainstem cavernomas: a consecutive 8-year series. J Neurosurg 99:31–37

    Article  PubMed  Google Scholar 

  18. Ohue S, Fukushima T, Kumon Y, Ohnishi T, Friedman AH (2009) Retrosigmoid suprafloccular transhorizontal fissure approach for resection of brainstem cavernous malformation. Neurosurgery (in press).

  19. Porter PJ, Willinsky RA, Harper W, Wallace MC (1997) Cerebral cavernous malformations: natural history and prognosis after clinical deterioration with or without hemorrhage. J Neurosurg 87:190–197

    Article  CAS  PubMed  Google Scholar 

  20. Porter RW, Detwiler PW, Spetzler RF, Lawton MT, Baskin JJ, Derksen PT, Zabramski JM (1999) Cavernous malformations of the brainstem: experience with 100 patients. J Neurosurg 90:50–58

    Article  CAS  PubMed  Google Scholar 

  21. Rigamonti D, Drayer BP, Johnson PC, Hadley MN, Zabramski J, Spetzler RF (1987) The MRI appearance of cavernous malformations (angiomas). J Neurosurg 67:518–524

    Article  CAS  PubMed  Google Scholar 

  22. Robinson JR Jr, Awad IA, Magdinec M, Paranandi L (1993) Factors predisposing to clinical disability in patients with cavernous malformations of the brain. Neurosurgery 32:730–735

    Article  PubMed  Google Scholar 

  23. Samii M, Eghbal R, Carvalho GA, Matthies C (2001) Surgical management of brainstem cavernomas. J Neurosurg 95:825–832

    Article  CAS  PubMed  Google Scholar 

  24. Simard JM, Garcia-Bengochea F, Ballinger WE Jr, Mickle JP, Quisling RG (1986) Cavernous angioma: a review of 126 collected and 12 new clinical cases. Neurosurgery 18:162–172

    Article  CAS  PubMed  Google Scholar 

  25. Sindou M, Yada J, Salord F (2000) Functional results after microsurgical resection of brain stem cavernous malformations: retrospective study of a 12 patient series and review of the recent literature. Acta Neurochir (Wien) 142:843–852

    Article  CAS  Google Scholar 

  26. Steinberg GK, Chang SD, Gewirtz RJ, Lopez JR (2000) Microsurgical resection of brainstem, thalamic, and basal ganglia angiographically occult vascular malformations. Neurosurgery 46:260–270

    Article  CAS  PubMed  Google Scholar 

  27. Strauss C, Lütjen-Drecoll E, Fahlbusch R (1997) Pericollicular surgical approaches to the rhomboid fossa. Part I. Anatomical basis. J Neurosurg 87:893–899

    Article  CAS  PubMed  Google Scholar 

  28. Symon L, Jackowski A, Bills D (1991) Surgical treatment of pontomedullary cavernomas. Br J Neurosurg 5:339–347

    Article  CAS  PubMed  Google Scholar 

  29. Tung H, Giannotta SL, Chandrasoma PT, Zee CS (1990) Recurrent intraparenchymal hemorrhages from angiographically occult vascular malformations. J Neurosurg 73:174–180

    Article  CAS  PubMed  Google Scholar 

  30. Wang CC, Liu A, Zhang JT, Sun B, Zhao YL (2003) Surgical management of brain-stem cavernous malformations: report of 137 cases. Surg Neurol 59:444–454

    Article  PubMed  Google Scholar 

  31. Zimmerman RS, Spetzler RF, Lee KS, Zabramski JM, Hargraves RW (1991) Cavernous malformations of the brain stem. J Neurosurg 75:32–39

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Neurosurgery, Duke University Medical Center, Durham, NC, 27710, USA

    Shiro Ohue, Takanori Fukushima & Allan H. Friedman

  2. Department of Neurosurgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan

    Shiro Ohue, Yoshiaki Kumon & Takanori Ohnishi

Authors
  1. Shiro Ohue
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  2. Takanori Fukushima
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  3. Yoshiaki Kumon
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  4. Takanori Ohnishi
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  5. Allan H. Friedman
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Correspondence to Shiro Ohue.

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Comments

Toshio Matsushima, Saga, Japan

The authors reported a large number of cases of brainstem cavernomas with good surgical results. They seem to have selected the approaches according to the relationship between the cavernoma and the pial or ependymal surface of the brainstem. In half of the cases, the midline suboccipital approach was utilized. Although they did not mention the trans-cerebellomedurally fissure approach, a special approach of the midline suboccipital approach, it is very useful for exposing the interior of the fourth ventricle without postoperative so-called “cerebellar mutism” syndrome. We use it to expose the floor or lateral walls of the fourth ventricle in cases of brainstem cavernoma. They did not describe the detail of the entry zone of the floor of the fourth ventricle in this paper. I hope they will perform further study on the relationships between the entry zone of the floor of the fourth ventricle and the postoperative neurological deficits using these 16 cases. For the sake of readers, I wish they had reported the details of the 3 postoperatively worsened cases.

Ulrich Sure, Erol I. Sandalcioglu, Essen, Germany

The paper entitled: “Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques” by the group of Fukushima and Friedmann from North Carolina is a very instructive summary of possible surgical corridors to the brainstem. It addresses the important considerations that have to be made for the proper selection of the optimal possible surgical approach. In addition to the presented surgical approaches for laterally located cavernomas of the midbrain/thalamus and ponto- mesencephalic lesions, our group has collected a very nice (and successful) experience with the posterior subtemporal (transtentorial) approach with a lumbar drainage prior to dura opening.

The authors nicely address the challenge of associated developmental venous anomalies that might play a serious role when it comes to the final decision for or even against a distinct surgical approach. Moreover, they elaborate the problem and possible reasons for the incomplete resection of cavernomas within the brainstem. Here, it would be of interest to evaluate whether these lesions were incompletely resected due to their adverse cleavage to the brainstem surface or simply might have recurred. The local recurrence of cavernomas is also well possible, particularly, when patients suffer from multiple lesions.

The authors have to be congratulated for the nice and instructive manuscript and figures as well as for their excellent surgical results with no mortality and a low rate of permanent surgical morbidity.

Uğur Ture, Praveen Baimeedi, İstanbul, Turkey

The authors review the detailed retrospective data of 36 patients with symptomatic brainstem cavernomas who underwent surgery over a 10-year period. They should be commended for their excellent work. We agree with the authors that symptomatic brainstem cavernomas should be operated on, and we also agree that some of the asymptomatic cavernomas should be managed conservatively. The timing of surgery after hemmorhage of a brainstem cavernoma is controversial and there is no uniform consensus. Some surgeons recommend subacute surgery while others propose early surgery. The authors prefer to operate at the subacute stage, which is certainly easier for the surgeon because the plane of cleavage is well defined and resection is hence less difficult. Our philosophy, however, is to operate as early as possible after hemorrhage because acute evacuation of the hematoma helps relieve compression-related neuronal dysfunction and expedite neuronal recovery. Late surgery on cavernomas is challenging; finding a dissection plane is difficult because the lesions tend to adhere and we do not have the luxury of being able to go around the gliotic plane for adherent lesions in the brainstem.

The main principles of surgical management of symptomatic brainstem cavernomas include the use of fine microsurgical techniques to completely resect the lesion and prevent future bleeding, evacuating the hematoma, and ensuring that no new permanent neurological damage occurs. In our experience, hematomas associated with cavernomas do not usually disrupt white matter tracts but displace them, evidence of which is apparent in how most of these patients eventually improve after surgery.

Recurrent hemorrhage after surgery stems from incomplete resection, which can be circumvented by using some form of intraoperative imaging, such as ultrasound or intraoperative MRI. We use intraoperative ultrasound to give us real-time feedback to confirm complete removal of the lesion after resection. Fiber tractography imaging is useful and the information obtained from the images helps determine the appropriate surgical route. Fiber dissection done to study the intrinsic anatomy of the brain stem helps interpret the fiber tractography images, and that data can be used to an advantage in brainstem surgery (1, 2). As exemplified in this paper, intraoperative neurophysiological monitoring is essential. The authors’ excellent results strengthen the fact that microsurgical management of symptomatic cavernomas continues to be the mainstay of treatment.

References

1. Kovanlikaya I, Firat Z, Kovanlikaya A, Mut M, Ulug A,Cihangiroglu M, Bingol C, Türe U: Assessment of the Corticospinal Tract Alterations Before and after Resection of Brainstem Lesions Using Diffusion Tensor Imaging (DTI) and Tractography at 3Tesla. Eur J Radiol. 2009, Sep 19. [Epub ahead of print].

2. Türe U, Yaşargil MG, Friedman AH, Al-Mefty O: Fiber Dissection Technique: Lateral Aspect of Brain. Neurosurgery 47: 417–427, 2000.

Helmut Bertalanffy, Zürich, Switzerland

This is a valuable contribution to the literature dealing with brainstem cavernous malformations. Management and outcome in this case series reflect the well-known experience and meticulous surgical technique of Dr. T. Fukushima and his colleagues. Although the topic is very complex, I would like to address here briefly only three issues: timing of surgery, completeness of resection and selection of approaches.

Contrary to the authors’ experience that removal of a brainstem cavernoma in the acute stage can cause neurological deterioration and difficulty in identifying the dissection plane, I am convinced that in many—if not in most—cases, particularly when a large intralesional hematoma has developed within days or a few weeks, immediate surgery in the acute stage is beneficial for the patient. I have seen patients in my own series in which complete removal of the cavernous malformation in the acute stage was followed by disappearance of the perilesional brainstem edema within a few days, and this correlated well with rapid clinical improvement. Defining the surgical plane was not more difficult in these cases than in others.

As for the completeness of surgical removal, I have also experienced a few cases of re-bleeding of most probably small residual portions of the vascular malformation, either early after surgery or later, up to 4 years postoperatively. However, I have not encountered a single case of brainstem cavernoma out of 127 individuals operated so far in which I had to deliberately leave parts of the lesion behind. It is well-known that residual cavernous malformation can be the source of re-bleeding. Indeed, in the present series, re-hemorrhage occurred in one out of three patients with residual cavernoma (33%). Therefore, I consider it most important to avoid by all means leaving visible and active parts of the cavernoma behind.

To be able to completely remove a lesion even if it is firmly adherent to the brainstem, selection of the optimal surgical approach is crucial. In many instances, one can choose between at least two reasonable approaches available in a specific case, though I never made the selection of the approach solely dependent on the lateralization of the lesion. A medial or mediolateral brainstem cavernoma that does not completely reach the surface of the rhomboid fossa may sometimes better be approached from laterally. With such a tactic one may avoid interference with the fibres of the facial nerve at the site of the facial colliculus. We have recently demonstrated a great variability in size, site and extent of the area of electrophysiological response of facial nerve fibres at the so-called facial colliculus of the rhomboid fossa. A good alternative to the midline approach is, as I have previously mentioned, the lateral access route at the level of the pontomedullary sulcus, between the exit of the facial and glossopharyngeal nerve fibres. This is an optimal site to enter the brainstem in order to reach deep-seated pontine lesions that are invisible at the surface of the brainstem while sparing the fibres of the caudal cranial nerves and their nuclei (1).

To summarize, I wish to commend the authors for their detailed analysis and their excellent clinical results.

Reference

1. Bertalanffy H: Intracranial cavernomas. In: Sindou M (ed). Practical Handbook of Neurosurgery. Vol. 1. Springer-Verlag Wien 2009, pp 325–34

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Ohue, S., Fukushima, T., Kumon, Y. et al. Surgical management of brainstem cavernomas: selection of approaches and microsurgical techniques. Neurosurg Rev 33, 315–324 (2010). https://doi.org/10.1007/s10143-010-0256-7

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