Alim P. Mitha, John H. Wong, Michael D. Hill and Mayank Goyal
Adib A. Abla, Jay D. Turner, Alim P. Mitha, Gregory Lekovic and Robert F. Spetzler
Brainstem cavernous malformations (CMs) are low-flow vascular lesions in eloquent locations. Their presentation is often marked with symptomatic hemorrhages that appear to occur more frequently than hemorrhage from supratentorial cavernomas. Brainstem CMs can be removed using 1 of the 5 standard skull-base approaches: retrosigmoid, suboccipital (with or without telovelar approach), supracerebellar infratentorial, orbitozygomatic, and far lateral.
Patients being referred to a tertiary institution often have lesions that are aggressive with respect to bleeding rates. Nonetheless, the indications for surgery, in the authors' opinion, are the same for all lesions: those that are symptomatic, those that cause mass effect, or those that abut a pial surface. Patients often have relapsing and remitting courses of symptoms, with each hemorrhage causing a progressive and stepwise decline. Many patients experience new postoperative deficits, most of which are transient and resolve fully. Despite the risks associated with operating in this highly eloquent tissue, most patients have had favorable outcomes in the authors' experience. Surgical treatment of brainstem CMs protects patients from the potentially devastating effects of rehemorrhage, and the authors believe that the benefits of intervention outweigh the risks in patients with the appropriate indications.
Michael K. Tso, Myunghyun M. Lee, Chad G. Ball, William F. Morrish, Alim P. Mitha, Andrew W. Kirkpatrick and John H. Wong
Blunt cerebrovascular injury (BCVI) occurs in approximately 1% of the blunt trauma population and may lead to stroke and death. Early vascular imaging in asymptomatic patients at high risk of having BCVI may lead to earlier diagnosis and possible stroke prevention. The objective of this study was to determine if the implementation of a formalized asymptomatic BCVI screening protocol with CT angiography (CTA) would lead to improved BCVI detection and stroke prevention.
Patients with vascular imaging studies were identified from a prospective trauma registry at a single Level 1 trauma center between 2002 and 2008. Detection of BCVI and stroke rates were compared during the 3-year periods before and after implementation of a consensus-based asymptomatic BCVI screening protocol using CTA in 2005.
A total of 5480 patients with trauma were identified. The overall BCVI detection rate remained unchanged postprotocol compared with preprotocol (0.8% [24 of 3049 patients] vs 0.9% [23 of 2431 patients]; p = 0.53). However, postprotocol there was a trend toward a decreased risk of stroke secondary to BCVI on a trauma population basis (0.23% [7 of 3049 patients] vs 0.53% [13 of 2431 patients]; p = 0.06). Overall, 75% (35 of 47) of patients with BCVI were treated with antiplatelet agents, but no patient developed new or progressive intracranial hemorrhage despite 70% of these patients having concomitant traumatic brain injury.
The results of this study suggest that a CTA screening protocol for BCVI may be of clinical benefit with possible reduction in ischemic complications. The treatment of BCVI with antiplatelet agents appears to be safe.