Surgical management of brainstem cavernomas

Restricted access

Object. A careful retrospective analysis of 36 cases was performed to evaluate the pre- and postoperative rates of morbidity that occur in patients with brainstem cavernous angiomas.

Methods. The authors evaluated immediate postoperative and follow-up outcomes with regard to clinical findings, the incidence of preoperative hemorrhage(s), location and size of the lesions, and the timing of the surgical procedure after the last hemorrhagic event. Specifically, the following parameters were analyzed: 1) number of hemorrhages; 2) the precise brainstem location (pontomesencephalic, pons, and medulla oblongata); 3) pre- and postoperative cranial nerve status; 4) pre- and postoperative motor and sensory deficits; 5) size (volume) of the lesions; and 6) pre- and postoperative Karnofsky Performance Scale (KPS) scores. Multiple hemorrhages were observed in 16 patients, particularly in those with pontomesencephalic cavernous angiomas (75%). The mean preoperative KPS score was 70.3 ± 16.3 (± standard deviation). Twenty-six patients (72.2%) presented with cranial nerve impairment, 13 (36.1%) with motor deficits, and 17 (47.2%) with sensory disturbance. Volume of the lesions ranged from 0.18 to 18.18 cm3 (mean 4.75 cm3). Postoperative complications included new cranial nerve deficits in 17 patients, motor deficits in three, and new sensory disturbances in 12 patients. In a mean follow-up period of 21.5 months, KPS scores were 80 to 100 in 22 patients. Timing of surgery (posthemorrhage) and multiple hemorrhages did not influence the long-term results. Higher preoperative KPS scores and smaller-volume lesions, however, were factors associated with a better final outcome (p < 0.05). Major morbidity was related mainly to preoperative status and less to surgical treatment. The incidence of new postoperative cranial nerve deficits was clearly lower than that demonstrated preoperatively because of the brainstem hemorrhages.

Conclusions. Based on these findings, resection of brainstem cavernomas is the treatment of choice in the majority of these cases because of the high incidence of morbidity related to one or often several brainstem hemorrhages.

Article Information

Contributor Notes

Address reprint requests to: Gustavo A. Carvalho, M.D., Neurochirurgische Klinik, Krankenhaus Nordstadt, Haltenhoffstrasse 41, Hannover 30167, Germany. email: gacarvalho@compuserve.com.
Headings
References
  • 1.

    Bertalanffy HGilsbach JMEggert HRet al: Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir 108:91991991Bertalanffy H Gilsbach JM Eggert HR et al: Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir 108:91–99 1991

    • Search Google Scholar
    • Export Citation
  • 2.

    Bien SFriedburg HHarders Aet al: Intracerebral cavernous angiomas in magnetic resonance imaging. Acta Radiol Suppl 369:79811986Bien S Friedburg H Harders A et al: Intracerebral cavernous angiomas in magnetic resonance imaging. Acta Radiol Suppl 369:79–81 1986

    • Search Google Scholar
    • Export Citation
  • 3.

    Biondi AScotti GScialfa Get al: Magnetic resonance imaging of cerebral cavernous angiomas. Acta Radiol Suppl 369:82851986Biondi A Scotti G Scialfa G et al: Magnetic resonance imaging of cerebral cavernous angiomas. Acta Radiol Suppl 369:82–85 1986

    • Search Google Scholar
    • Export Citation
  • 4.

    Cantore GMissori PSantoro A: Cavernous angiomas of the brain stem. Intra-axial anatomical pitfalls and surgical strategies. Surg Neurol 52:84941999Cantore G Missori P Santoro A: Cavernous angiomas of the brain stem. Intra-axial anatomical pitfalls and surgical strategies. Surg Neurol 52:84–94 1999

    • Search Google Scholar
    • Export Citation
  • 5.

    Di Rocco CIannelli ATamburrini G: Cavernous angiomas of the brain stem in children. Pediatr Neurosurg 27:92991997Di Rocco C Iannelli A Tamburrini G: Cavernous angiomas of the brain stem in children. Pediatr Neurosurg 27:92–99 1997

    • Search Google Scholar
    • Export Citation
  • 6.

    Dorsch NWCMcMahon JHA: Intracranial cavernous malformations—natural history and management. Crit Rev Neurosurg 8:1541681998Dorsch NWC McMahon JHA: Intracranial cavernous malformations—natural history and management. Crit Rev Neurosurg 8:154–168 1998

    • Search Google Scholar
    • Export Citation
  • 7.

    Drake CGFriedman AHPeerless SJ: Posterior fossa arteriovenous malformations. J Neurosurg 64:1101986Drake CG Friedman AH Peerless SJ: Posterior fossa arteriovenous malformations. J Neurosurg 64:1–10 1986

    • Search Google Scholar
    • Export Citation
  • 8.

    Eisner WSchmid UDReulen HJet al: The mapping and continuous monitoring of the intrinsic motor nuclei during brain stem surgery. Neurosurgery 37:2552651995Eisner W Schmid UD Reulen HJ et al: The mapping and continuous monitoring of the intrinsic motor nuclei during brain stem surgery. Neurosurgery 37:255–265 1995

    • Search Google Scholar
    • Export Citation
  • 9.

    Fahlbusch RStrauss CHuk W: Pontine-mesencephalic cavernomas: indications for surgery and operative results. Acta Neurochir Suppl 53:37411991Fahlbusch R Strauss C Huk W: Pontine-mesencephalic cavernomas: indications for surgery and operative results. Acta Neurochir Suppl 53:37–41 1991

    • Search Google Scholar
    • Export Citation
  • 10.

    Fahlbusch RStrauss CHuk Wet al: Surgical removal of pontomesencephalic cavernous hemangiomas. Neurosurgery 26:4494571990Fahlbusch R Strauss C Huk W et al: Surgical removal of pontomesencephalic cavernous hemangiomas. Neurosurgery 26:449–457 1990

    • Search Google Scholar
    • Export Citation
  • 11.

    Fritschi JAReulen HJSpetzler RFet al: Cavernous malformations of the brain stem. A review of 139 cases. Acta Neurochir 130:35461994Fritschi JA Reulen HJ Spetzler RF et al: Cavernous malformations of the brain stem. A review of 139 cases. Acta Neurochir 130:35–46 1994

    • Search Google Scholar
    • Export Citation
  • 12.

    Heffez DSZinreich SJLong DM: Surgical resection of intrinsic brain stem lesions: an overview. Neurosurgery 27:7897981990Heffez DS Zinreich SJ Long DM: Surgical resection of intrinsic brain stem lesions: an overview. Neurosurgery 27:789–798 1990

    • Search Google Scholar
    • Export Citation
  • 13.

    Houtteville JP: Brain cavernoma: a dynamic lesion. Surg Neurol 48:6106141997Houtteville JP: Brain cavernoma: a dynamic lesion. Surg Neurol 48:610–614 1997

    • Search Google Scholar
    • Export Citation
  • 14.

    Huber GPiepgras UHenkes Het al: Venenanomalien des Gehirns. Zur klinischen Bedeutung des sogenannten venosen Angioms. Radiologe 31:2742821991Huber G Piepgras U Henkes H et al: Venenanomalien des Gehirns. Zur klinischen Bedeutung des sogenannten venosen Angioms. Radiologe 31:274–282 1991

    • Search Google Scholar
    • Export Citation
  • 15.

    Karlsson BKihlstrom LLindquist Cet al: Radiosurgery for cavernous malformations. J Neurosurg 88:2932971998Karlsson B Kihlstrom L Lindquist C et al: Radiosurgery for cavernous malformations. J Neurosurg 88:293–297 1998

    • Search Google Scholar
    • Export Citation
  • 16.

    Karnofsky DABurchenal JHArmistead GC Jr: Triethylenemelamine in the treatment of neoplastic disease. A compound with nitrogen-mustard-like activity suitable for oral and intravenous use. Arch Intern Med 87:4775151951Karnofsky DA Burchenal JH Armistead GC Jr: Triethylenemelamine in the treatment of neoplastic disease. A compound with nitrogen-mustard-like activity suitable for oral and intravenous use. Arch Intern Med 87:477–515 1951

    • Search Google Scholar
    • Export Citation
  • 17.

    LeDoux MSAronin PAOdrezin GT: Surgically treated cavernous angiomas of the brain stem: report of two cases and review of the literature. Surg Neurol 35:3953991991LeDoux MS Aronin PA Odrezin GT: Surgically treated cavernous angiomas of the brain stem: report of two cases and review of the literature. Surg Neurol 35:395–399 1991

    • Search Google Scholar
    • Export Citation
  • 18.

    Lee RRBecher MWBenson MLet al: Brain capillary telangiectasia: MR imaging appearance and clinicohistopathologic findings. Radiology 205:7978051997Lee RR Becher MW Benson ML et al: Brain capillary telangiectasia: MR imaging appearance and clinicohistopathologic findings. Radiology 205:797–805 1997

    • Search Google Scholar
    • Export Citation
  • 19.

    Liscak RVladyka VSimonova Get al: Gamma knife radio-surgery of the brain stem cavernomas. Minim Invasive Neurosurg 43:2012072000Liscak R Vladyka V Simonova G et al: Gamma knife radio-surgery of the brain stem cavernomas. Minim Invasive Neurosurg 43:201–207 2000

    • Search Google Scholar
    • Export Citation
  • 20.

    Lynch JCAndrade RPereira Cet al: Angioma cavernoso intracraniano. Arq Neuropsiquiatr 52:2372421994Lynch JC Andrade R Pereira C et al: Angioma cavernoso intracraniano. Arq Neuropsiquiatr 52:237–242 1994

    • Search Google Scholar
    • Export Citation
  • 21.

    Meixensberger JHofmann ERoosen K: Zerebrale Kavernome—Klinik und Therapie. Wien Med Wochenschr 147:1941981997Meixensberger J Hofmann E Roosen K: Zerebrale Kavernome—Klinik und Therapie. Wien Med Wochenschr 147:194–198 1997

    • Search Google Scholar
    • Export Citation
  • 22.

    Mizoi KYoshimoto TSuzuki J: Clinical analysis of ten cases with surgically treated brain stem cavernous angiomas. Tohoku J Exp Med 166:2592671992Mizoi K Yoshimoto T Suzuki J: Clinical analysis of ten cases with surgically treated brain stem cavernous angiomas. Tohoku J Exp Med 166:259–267 1992

    • Search Google Scholar
    • Export Citation
  • 23.

    Morcos JJHeros RCFrank DE: Microsurgical treatment of infratentorial malformations. Neurosurg Clin N Am 10:4414741999Morcos JJ Heros RC Frank DE: Microsurgical treatment of infratentorial malformations. Neurosurg Clin N Am 10:441–474 1999

    • Search Google Scholar
    • Export Citation
  • 24.

    Moriarity JLClatterbuck RERigamonti D: The natural history of cavernous malformations. Neurosurg Clin N Am 10:4114171999Moriarity JL Clatterbuck RE Rigamonti D: The natural history of cavernous malformations. Neurosurg Clin N Am 10:411–417 1999

    • Search Google Scholar
    • Export Citation
  • 25.

    Ojemann RGCrowell RMOgilvy CS: Surgical management of cavernous angiomas of the nervous system in Schmidek HHSweet WH (eds): Operative Neurosurgical Techniques. Indication Methods and Resultsed 3. Philadelphia: WB Saunders1995 Vol 2 pp 11831196Ojemann RG Crowell RM Ogilvy CS: Surgical management of cavernous angiomas of the nervous system in Schmidek HH Sweet WH (eds): Operative Neurosurgical Techniques. Indication Methods and Results ed 3. Philadelphia: WB Saunders 1995 Vol 2 pp 1183–1196

    • Search Google Scholar
    • Export Citation
  • 26.

    Pozzati EAcciarri NTognetti Fet al: Growth, subsequent bleeding, and de novo appearance of cerebral cavernous angiomas. Neurosurgery 38:6626701996Pozzati E Acciarri N Tognetti F et al: Growth subsequent bleeding and de novo appearance of cerebral cavernous angiomas. Neurosurgery 38:662–670 1996

    • Search Google Scholar
    • Export Citation
  • 27.

    Raps ECGaletta SLKing JT Jret al: Isolated one-and-a-half syndrome with pontine cavernous angioma: successful surgical removal. J Clin Neuroophthalmol 10:2872901990Raps EC Galetta SL King JT Jr et al: Isolated one-and-a-half syndrome with pontine cavernous angioma: successful surgical removal. J Clin Neuroophthalmol 10:287–290 1990

    • Search Google Scholar
    • Export Citation
  • 28.

    Rigamonti DHadley MNDrayer BPet al: Cerebral cavernous malformations. Incidence and familial occurrence. N Engl J Med 319:3433471988Rigamonti D Hadley MN Drayer BP et al: Cerebral cavernous malformations. Incidence and familial occurrence. N Engl J Med 319:343–347 1988

    • Search Google Scholar
    • Export Citation
  • 29.

    Rigamonti DSpetzler RF: The association of venous and cavernous malformations. Report of four cases and discussion of the pathophysiological, diagnostic, and therapeutic implications. Acta Neurochir 92:1001051988Rigamonti D Spetzler RF: The association of venous and cavernous malformations. Report of four cases and discussion of the pathophysiological diagnostic and therapeutic implications. Acta Neurochir 92:100–105 1988

    • Search Google Scholar
    • Export Citation
  • 30.

    Rigamonti DSpetzler RFDrayer BPet al: Appearance of venous malformations on magnetic resonance imaging. J Neurosurg 69:5355391988Rigamonti D Spetzler RF Drayer BP et al: Appearance of venous malformations on magnetic resonance imaging. J Neurosurg 69:535–539 1988

    • Search Google Scholar
    • Export Citation
  • 31.

    Robinson JRAwad IALittle JR: Natural history of the cavernous angioma. J Neurosurg 75:7097141991Robinson JR Awad IA Little JR: Natural history of the cavernous angioma. J Neurosurg 75:709–714 1991

    • Search Google Scholar
    • Export Citation
  • 32.

    Sakai NSakai HGotoh Yet al: [Surgical treatment of brain stem lesions with reference to cavernous angioma.] No To Shinkei 44:9839881992 (Jpn)Sakai N Sakai H Gotoh Y et al: [Surgical treatment of brain stem lesions with reference to cavernous angioma.] No To Shinkei 44:983–988 1992 (Jpn)

    • Search Google Scholar
    • Export Citation
  • 33.

    Sass FBouche CLeitner A: Flächen und Körperberechnung in Sass FBouche CLeitner A (eds): Dubbels Taschenbuch für den Maschinenbaued 12. Berlin: Springer-Verlag1966 pp 187188Sass F Bouche C Leitner A: Flächen und Körperberechnung in Sass F Bouche C Leitner A (eds): Dubbels Taschenbuch für den Maschinenbau ed 12. Berlin: Springer-Verlag 1966 pp 187–188

    • Search Google Scholar
    • Export Citation
  • 34.

    Simard JMGarcia-Bengochea FBallinger WE Jret al: Cavernous angioma: a review of 126 collected and 12 new clinical cases. Neurosurgery 18:1621721986Simard JM Garcia-Bengochea F Ballinger WE Jr et al: Cavernous angioma: a review of 126 collected and 12 new clinical cases. Neurosurgery 18:162–172 1986

    • Search Google Scholar
    • Export Citation
  • 35.

    Stein BMSolomon RA: Surgical approaches to posterior fossa arteriovenous malformations. Clin Neurosurg 37:3533711991Stein BM Solomon RA: Surgical approaches to posterior fossa arteriovenous malformations. Clin Neurosurg 37:353–371 1991

    • Search Google Scholar
    • Export Citation
  • 36.

    Steinberg GKChang SDGewirtz RJet al: Microsurgical resection of brainstem, thalamic, and basal ganglia angiographically occult vascular malformations. Neurosurgery 46:2602712000Steinberg GK Chang SD Gewirtz RJ et al: Microsurgical resection of brainstem thalamic and basal ganglia angiographically occult vascular malformations. Neurosurgery 46:260–271 2000

    • Search Google Scholar
    • Export Citation
  • 37.

    Strauss CFahlbusch R: Anatomical aspects for surgery within the floor of the IVth ventricle. Zentralbl Neurochir 58:7121997Strauss C Fahlbusch R: Anatomical aspects for surgery within the floor of the IVth ventricle. Zentralbl Neurochir 58:7–12 1997

    • Search Google Scholar
    • Export Citation
  • 38.

    Strauss CRomstock JNimsky Cet al: Intraoperative identification of motor areas of the rhomboid fossa using direct stimulation. J Neurosurg 79:3933991993Strauss C Romstock J Nimsky C et al: Intraoperative identification of motor areas of the rhomboid fossa using direct stimulation. J Neurosurg 79:393–399 1993

    • Search Google Scholar
    • Export Citation
  • 39.

    Symon LJackowski ABills D: Surgical treatment of pontomedullary cavernomas. Br J Neurosurg 5:3393471991Symon L Jackowski A Bills D: Surgical treatment of pontomedullary cavernomas. Br J Neurosurg 5:339–347 1991

    • Search Google Scholar
    • Export Citation
  • 40.

    Weil SMTew JM Jr: Surgical management of brain stem vascular malformations. Acta Neurochir 105:14231990Weil SM Tew JM Jr: Surgical management of brain stem vascular malformations. Acta Neurochir 105:14–23 1990

    • Search Google Scholar
    • Export Citation
  • 41.

    Wowra BLayer GSchad LRet al: Three-dimensional time-of-flight MR-angiography and the surgical indication of brainstem cavernomas. Acta Neurochir 112:77821991Wowra B Layer G Schad LR et al: Three-dimensional time-of-flight MR-angiography and the surgical indication of brainstem cavernomas. Acta Neurochir 112:77–82 1991

    • Search Google Scholar
    • Export Citation
  • 42.

    Yoshimoto TSuzuki J: Radical surgery on cavernous angioma of the brainstem. Surg Neurol 26:72781986Yoshimoto T Suzuki J: Radical surgery on cavernous angioma of the brainstem. Surg Neurol 26:72–78 1986

    • Search Google Scholar
    • Export Citation
  • 43.

    Zabramski JMWascher TMSpetzler RFet al: The natural history of familial cavernous malformations: results of an ongoing study. J Neurosurg 80:4224321994Zabramski JM Wascher TM Spetzler RF et al: The natural history of familial cavernous malformations: results of an ongoing study. J Neurosurg 80:422–432 1994

    • Search Google Scholar
    • Export Citation
  • 44.

    Zimmerman RSSpetzler RFLee KSet al: Cavernous malformations of the brain stem. J Neurosurg 75:32391991Zimmerman RS Spetzler RF Lee KS et al: Cavernous malformations of the brain stem. J Neurosurg 75:32–39 1991

    • Search Google Scholar
    • Export Citation
TrendMD
Cited By
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 736 582 31
Full Text Views 361 87 1
PDF Downloads 161 48 1
EPUB Downloads 0 0 0
PubMed
Google Scholar