Emergency resection of brainstem cavernous malformations

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Brainstem cavernous malformations (CMs) pose significant challenges to neurosurgeons because of their deep locations and high surgical risks. Most patients with brainstem CMs present with sudden-onset cranial nerve deficits or ataxia, but uncommonly patients can present in extremis from an acute hemorrhage, requiring surgical intervention. However, the timing of surgery for brainstem CMs has been a controversial topic. Although many authors propose delaying surgery into the subacute phase, some patients may not tolerate waiting until surgery. To the best of the authors’ knowledge, emergency surgery after a brainstem CM hemorrhage has not been described. In cases of rapidly progressive neurological deterioration, emergency resection may often be the only option. In this retrospectively reviewed small series of patients, the authors report favorable outcomes after emergency surgery for resection of brainstem CMs.

ABBREVIATIONS CM = cavernous malformation; CN = cranial nerve; EMG = electromyography; EVD = external ventricular drain; GCS = Glasgow Coma Scale; GTR = gross-total resection; KPS = Karnofsky Performance Scale; MEP = motor evoked potential; mRS = modified Rankin Scale; SSEP = somatosensory evoked potential.

Article Information

Correspondence Mustafa K. Baskaya, Department of Neurological Surgery, University of Wisconsin–Madison, School of Medicine, CSC, K4/882, 600 Highland Ave., Madison, WI 53792. email: baskaya@neurosurgery.wisc.edu.

INCLUDE WHEN CITING Published online July 7, 2017; DOI: 10.3171/2017.1.JNS161693.

Drs. Tumturk and Li contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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    Case 1. Preoperative axial CT scan (A) and axial T2-weighted MR image (B) show acute and hyperacute phases of hemorrhage in the pons. Axial T1-weighted postcontrast MR image (C) shows minimal enhancement within the lesion at the level of the internal acoustic canal. Sagittal T1-weighted postcontrast MR image (D) shows an expansile mass in the pons with significant mass effect on the basilar artery.

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    Case 1. Postoperative axial T1-weighted postcontrast (A), sagittal T2-weighted (B), and coronal T2-weighted (C) MR images show no obvious residual CM and significant improvement of mass effect.

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    Case 2. Preoperative axial CT scan (A) and axial T2-weighted MR images (B and C) show acute and hyperacute phases of hemorrhage in the midbrain, pons, and right cerebral peduncle with a cystic component and obstructive hydrocephalus. Axial T1-weighted postcontrast (D), sagittal T1-weighted postcontrast (E), and coronal T2-weighted FLAIR (F) MR images show a heterogenic enhancing mass involving the pons and the right cerebral peduncle extending into the fourth ventricle, as well as the anterior pons.

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    Case 2. Postoperative axial T1-weighted postcontrast (A), sagittal T2-weighted CUBE-FLAIR (B), and coronal T2-weighted CUBE-FLAIR (C) MR images show no obvious residual CM and significant improvement of mass effect.

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    Case 3. Preoperative axial CT scan (A) and axial T2-weighted MR image (B) show a hemorrhagic lesion involving the pons and left cerebral peduncle. An axial T1-weighted postcontrast MR image (C) shows a minimally enhancing lesion in the pons. Sagittal T2-weighted (D) and coronal T2-weighted CUBE-FLAIR (E) MR images show an expansile mass in the pons with significant mass effect.

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    Case 3. Postoperative axial T1-weighted postcontrast (A), and sagittal (B) and coronal T2-weighted CUBE-FLAIR (C) MR images show no obvious residual CM and significant improvement of mass effect.

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    Case 4. Preoperative axial T2-weighted (A), axial T1-weighted postcontrast (B), sagittal T1-weighted postcontrast (C), and coronal T2-weighted (D) MR images show a very large hemorrhagic contrast-enhancing CM involving the left lateral pons and cerebellar peduncle at the level of the left cerebellopontine angle.

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    Case 4. Postoperative axial T2-weighted (A), axial T1-weighted postcontrast (B), and coronal T2-weighted (C) MR images show no obvious residual CM and preserved venous anomaly adjacent to the resection bed (A).

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