Original ArticleSurgical Management and Functional Outcomes of Cavernous Malformations Involving the Medulla Oblongata
Introduction
Brainstem cavernous malformations (CMs) are low-flow vascular lesions characterized by accidental repeated bleeding, which can result in significant neurologic morbidity or even mortality.1, 2, 3, 4 CMs involving the medulla oblongata may be more harmful to patients than those in other locations in the brainstem because of the complicated and vital neural structures, such as the corticospinal tracts (or pyramid), brainstem respiratory network, and vagus nerve nuclei, which are densely located in the small medulla oblongata.5, 6, 7 Slight changes or injury of the medulla oblongata caused by surgical manipulation may be accompanied by life-threatening complications, such as cardiovascular and respiratory instabilities.6, 8 However, surgical treatment of CMs involving the medulla oblongata is rarely distinguished by authors from those involving the brainstem, nor are the associated morbidities of respiration, circulation, and lower cranial nerves because of their rare occurrence.1, 7, 9 Moreover, debate still exists regarding which patients will benefit most from surgical intervention, even though numerous studies have attempted to identify predictors of good outcome in patients with brainstem CMs.9, 10 Therefore, we retrospectively reviewed a single-center series of 69 cases of CMs involving the medulla oblongata, including lesions in the pontomedullary and cervicomedullary junctions, to evaluate surgical treatment with associated complications and to identify the prognostic risk factors of long-term functional outcomes.
Section snippets
Study Population
The clinical data from 69 patients who underwent surgical treatment of CMs involving the medulla oblongata between January 2011 and January 2017 in our institute were retrospectively reviewed. The Beijing Tiantan Hospital Research Ethics Committee approved this study.
All neuroimaging data were reviewed by independent neuroradiologists. The definition of a hemorrhagic event was as follows: a clear clinical history of an acute, new-onset, or worsening focal neurologic deficit, accompanied by
Patient Demographics
A total of 69 patients received diagnoses of CMs involving the medulla oblongata and were microsurgically treated Their mean age was 32.6 ± 13.3 years (range, 8–64 years), and the male/female ratio was 1.3 (Table 1). All patients presented with a clear history of symptomatic hemorrhage before undergoing microsurgical resection. Among those patients, 34 (49.3%) had 2 hemorrhages, 7 (10.1%) had 3 hemorrhages, and 1 (1.4%) had 4 hemorrhages. A total of 120 hemorrhagic events across 2249
Discussion
The medulla oblongata is a vital neurologic zone in the brainstem with densely clustered neural structures. Slight changes in or injury to the medulla oblongata caused by compression of CMs or by surgical manipulation may result in obvious or severe neurologic deficits.6, 7, 8 The clinical symptoms of CMs involving the medulla vary among lesion locations and characteristics, which were mainly associated with deficits in the lower cranial nerves (or related nuclei), motor tracts, sensory tracts,
Conclusions
Respiratory dysfunction and deficits of cough reflexes are common and dangerous complications during the early postoperative period for surgical resection of CMs involving the medulla oblongata. However, favorable functional long-term outcome can be achieved in surgery, especially for younger patients who experienced fewer hemorrhages and have lesions presenting with perilesional edema and absence of DVAs.
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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.