Elsevier

World Neurosurgery

Volume 80, Issues 1–2, July–August 2013, Pages 89-93
World Neurosurgery

Peer-Review Report
Brainstem Cavernous Malformations: 1390 Surgical Cases from the Literature

https://doi.org/10.1016/j.wneu.2012.04.002Get rights and content

Objective

Although surgical resection of brainstem cavernous malformations (CM) has been reviewed, numerous large surgical series have been recently reported.

Methods

Eighteen new surgical series with 710 patients were found via a PubMed search, in addition to our previous meta-analysis. Complete excision, complications, and long-term outcome results were compiled across these series. They were then compared and subsequently combined with those of our previous report.

Results

We combined results of 68 surgical series with 1390 patients, incorporating results from our previous meta-analysis. Across 61 series, 1178 of 1291 (91%) CMs were completely excised. Of 105 partially resected CMs with ample follow-up, 65 rebled (62%). Across 46 series providing information on early neurologic morbidity, the overall rate was 45%. Specifically, 12% of patients required tracheostomy and/or gastrostomy procedures. Overall long-term condition was improved in 62% of patients across 51 series. Across 60 series, overall long-term condition was improved or the same in 84% of patients, with worsening in the remaining 16%. The overall surgical and/or cavernoma related mortality rate for all 1390 patients was 1.5%. Notably, these results did not differ significantly between our initial review and the combined data from the subsequent 18 surgical series recently reported in the literature.

Conclusion

Surgical resection of brainstem CM continues to present a considerable challenge with resultant morbidity akin to another CM hemorrhage. We therefore prefer to offer surgery only to patients with at least one previous hemorrhage with CM pial representation. Appropriate patient counseling about expected early morbidity and the potential for long-term worsening is crucial.

Introduction

Among the variety of lesions faced by vascular neurosurgeons, brainstem cavernous malformations (CMs) present a considerable microsurgical challenge and were once the subject of rare case reports (13, 45, 51). After large series were reported by the Barrow Neurological Institute in 1999 (40) and the Beijing Neurosurgical Institute in 2003 (53), an explosion of studies surfaced in the literature detailing the results of surgical resection (9, 16, 18, 50). Amidst this, we previously amassed results from 52 surgical series with 821 patients and found a 92% complete excision rate with 85% of patients being improved or the same at long-term follow-up (18). Impressively, since this initial report, a litany of series with nearly as many patients have been reported (1, 2, 6, 10, 11, 12, 15, 17, 20, 22, 23, 30, 32, 36, 42, 44, 49, 50), prompting us to amass their results, compare them, and combine them with those of our previous report.

Section snippets

Methods

The PubMed database was queried with the search terms “cavernoma,” “cavernous malformation,” “cavernous angioma,” “brainstem,” and “surgery” from May 2008 to January 2012. As per our previous selection criteria, any series containing at least three patients with brainstem CMs undergoing surgery was included. This resulted in 18 reports (1, 2, 6, 10, 11, 12, 15, 17, 20, 22, 23, 30, 32, 36, 42, 44, 49, 50), two of which were inclusive, larger updates of previous series in the literature (2, 5, 15

Results

During the last 3.5 years, 18 surgical series containing at least three patients with brainstem CMs were reported, including the largest study of 260 patients reported by Abla et al. (2). These 18 series included a total of 710 patients (median: 26.5 patients), a similar total to the 821 patients presented across 52 surgical series over the prior 21 years. Results are summarized in Table 1.

Comparing these new series to those amassed in our previous report (Table 2), we found the same 92%

Discussion

Previously confused with demyelinating disease (3, 7, 52), brainstem gliomas (47, 55), and even strokes (25, 27), brainstem CMs are now recognized as a curable cause of morbid brainstem injury. Concomitant with advances in magnetic resonance imaging techniques, small surgical series detailing the resection of brainstem CMs began to surface in the late 1980s (29, 55) with a subsequent explosion of studies undertaken during the past decade (2, 9, 15, 16, 18, 50, 53). Although the results provided

Conclusion

Brainstem CMs continue to present a considerable microsurgical challenge, with high early postoperative morbidity rates (45%) and long-term worsening in approximately 15% of patients after surgery. Complete excision, achieved in 91% of cases overall, should be the goal, as 62% of partially resected CMs rebled postoperatively. Even as an alternative only to observation, CM SRS is still reviewed with skepticism.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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