A taxonomy for brainstem cavernous malformations: subtypes of medullary lesions

Joshua S. CatapanoDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Joshua S. Catapano in
Current site
Google Scholar
PubMed
Close
 MD
,
Kavelin RumallaDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Kavelin Rumalla in
Current site
Google Scholar
PubMed
Close
 MD
,
Visish M. SrinivasanDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Visish M. Srinivasan in
Current site
Google Scholar
PubMed
Close
 MD
,
Peter M. LawrenceDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Peter M. Lawrence in
Current site
Google Scholar
PubMed
Close
 MS, CMI
,
Kristen Larson KeilDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Kristen Larson Keil in
Current site
Google Scholar
PubMed
Close
 MS, CMI
, and
Michael T. LawtonDepartment of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Search for other papers by Michael T. Lawton in
Current site
Google Scholar
PubMed
Close
 MD
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $525.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $624.00
USD  $45.00
USD  $525.00
USD  $624.00
Print or Print + Online Sign in

OBJECTIVE

Medullary cavernous malformations are the least common of the brainstem cavernous malformations (BSCMs), accounting for only 14% of lesions in the authors’ surgical experience. In this article, a novel taxonomy for these lesions is proposed based on clinical presentation and anatomical location.

METHODS

The taxonomy system was applied to a large 2-surgeon experience over a 30-year period (1990–2019). Of 601 patients who underwent microsurgical resection of BSCMs, 551 were identified who had the clinical and radiological information needed for inclusion. These 551 patients were classified by lesion location: midbrain (151 [27%]), pons (323 [59%]), and medulla (77 [14%]). Medullary lesions were subtyped on the basis of their predominant surface presentation. Neurological outcomes were assessed according to the modified Rankin Scale (mRS), with an mRS score ≤ 2 defined as favorable.

RESULTS

Five distinct subtypes were defined for the 77 medullary BSCMs: pyramidal (3 [3.9%]), olivary (35 [46%]), cuneate (24 [31%]), gracile (5 [6.5%]), and trigonal (10 [13%]). Pyramidal lesions are located in the anterior medulla and were associated with hemiparesis and hypoglossal nerve palsy. Olivary lesions are found in the anterolateral medulla and were associated with ataxia. Cuneate lesions are located in the posterolateral medulla and were associated with ipsilateral upper-extremity sensory deficits. Gracile lesions are located outside the fourth ventricle in the posteroinferior medulla and were associated with ipsilateral lower-extremity sensory deficits. Trigonal lesions in the ventricular floor were associated with nausea, vomiting, and diplopia. A single surgical approach was preferred (> 90% of cases) for each medullary subtype: the far lateral approach for pyramidal and olivary lesions, the suboccipital-telovelar approach for cuneate lesions, the suboccipital-transcisterna magna approach for gracile lesions, and the suboccipital-transventricular approach for trigonal lesions. Of these 77 patients for whom follow-up data were available (n = 73), 63 (86%) had favorable outcomes and 67 (92%) had unchanged or improved functional status.

CONCLUSIONS

This study confirms that the constellation of neurological signs and symptoms associated with a hemorrhagic medullary BSCM subtype is useful for defining the BSCM clinically according to a neurologically recognizable syndrome at the bedside. The proposed taxonomical classifications may be used to guide the selection of surgical approaches, which may enhance the consistency of clinical communications and help improve patient outcomes.

ABBREVIATIONS

AVM = arteriovenous malformation; BSCM = brainstem CM; CM = cavernous malformation; CN = cranial nerve; mRS = modified Rankin Scale; PICA = posterior inferior cerebellar artery; p1 = anterior medullary segment of the PICA; p2 = lateral medullary segment of the PICA; p3 = tonsillomedullary segment of the PICA; SEZ = safe entry zone; V4 = intradural segment of the vertebral artery.
  • Collapse
  • Expand

Figure from Ramos et al. (pp 95–103).

  • 1

    Haines DE. Fundamental Neuroscience for Basic and Clinical Applications. 4th ed. Elsevier;2013.

  • 2

    Rhoton A. Rhoton: Cranial Anatomy and Surgical Approaches: Neurosurgery. 1st ed. Lippincott Williams & Wilkins;2008.

  • 3

    Spetzler RF, Kalani MY, Nakaji P, Yagmurlu K. Color Atlas of the Brainstem Surgery. 1st ed. Thieme;2017.

  • 4

    Giliberto G, Lanzino DJ, Diehn FE, Factor D, Flemming KD, Lanzino G. Brainstem cavernous malformations: anatomical, clinical, and surgical considerations. Neurosurg Focus. 2010;29(3):E9.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Abla AA, Turner JD, Mitha AP, Lekovic G, Spetzler RF. Surgical approaches to brainstem cavernous malformations. Neurosurg Focus. 2010;29(3):E8.

  • 6

    Han SJ, Englot DJ, Kim H, Lawton MT. Brainstem arteriovenous malformations: anatomical subtypes, assessment of "occlusion in situ" technique, and microsurgical results. J Neurosurg. 2015;122(1):107117.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Lawton MT. Seven AVMs: Tenets and Techniques for Resection. Thieme;2014.

  • 8

    Lawton MT, Lang MJ. The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms. J Neurosurg. 2019;130(5):14091425.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Catapano JS, Rumalla K, Srinivasan VM, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for brainstem cavernous malformations: subtypes of midbrain lesions. J Neurosurg. Published online December 17, 2021.doi: 10.3171/2021.8.JNS211694

    • Search Google Scholar
    • Export Citation
  • 10

    Kim JS, Han YS. Medial medullary infarction: clinical, imaging, and outcome study in 86 consecutive patients. Stroke. 2009;40(10):32213225.

  • 11

    Spiller WG. The symptom-complex of a lesion of the upper most portion of the anterior spinal and adjoining portion of the vertebral arteries. J Nerv Ment Dis. 1908;(35):775777.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Dejerine J. Semiologie des affections du système nerveux. Masson;1914:226230.

  • 13

    Cavalcanti DD, Preul MC, Kalani MY, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg. 2016;124(5):13591376.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Miao HL, Zhang DY, Wang T, Jiao XT, Jiao LQ. Clinical importance of the posterior inferior cerebellar artery: a review of the literature. Int J Med Sci. 2020;17(18):30053019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Wallenberg’s lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. Arch Neurol. 1993;50(6):609614.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Catapano JS, Rumalla K, Srinivasan VM, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for brainstem cavernous malformations: subtypes of pontine lesions. Part 1: basilar, peritrigeminal, and middle peduncular. J Neurosurg. Published online March 25, 2022. doi: 10.3171/2022.1.JNS212690

    • Search Google Scholar
    • Export Citation
  • 17

    Catapano JS, Rumalla K, Srinivasan VM, Lawrence PM, Larson Keil K, Lawton MT. A taxonomy for brainstem cavernous malformations: subtypes of pontine lesions. Part 2: inferior peduncular, rhomboid, and supraolivary. J Neurosurg. Published online March 25, 2022. doi: 10.3171/2022.1.JNS212691

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 2173 2173 95
Full Text Views 393 393 90
PDF Downloads 624 624 140
EPUB Downloads 0 0 0