Recurrent brainstem cavernous malformations following primary resection: blind spots, fine lines, and the right-angle method

View More View Less
  • 1 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
  • 2 Department of Neurological Surgery, University of California, San Francisco, California
Restricted access

Purchase Now

USD  $45.00

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

USD  $505.00

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

USD  $600.00
Print or Print + Online

OBJECTIVE

Proximity of brainstem cavernous malformations (BSCMs) to tracts and cranial nerve nuclei make it costly to transgress normal tissue in accessing the lesion or disrupting normal tissue adjacent to the lesion in the separation plane. This interplay between tissue sensitivity and extreme eloquence makes it difficult to avoid leaving a remnant on occasion. Recurrences require operative intervention, which may increase morbidity, lengthen recovery, and add to overall costs. An approximately 20-year experience with patients with recurrent BSCM lesions following primary microsurgical resection was reviewed.

METHODS

A prospectively maintained database of 802 patients who underwent microsurgical resection of cerebral cavernous malformations during 1997–2018 was queried to identify 213 patients with BSCMs. A retrospective chart review was conducted for patients with recurrent BSCM after primary resection who required a second surgery.

RESULTS

Fourteen of 213 patients (6.6%) underwent repeat resection for recurrent BSCM. Thirty-four hemorrhagic events were observed among these 14 patients over 576 patient-years (recurrent hemorrhage rate, 5.9% per year; median discrete hemorrhagic events, 2; median time to rehemorrhage, 897 days). BSCM occurred in the pons in 10 cases, midbrain in 2 cases, and medulla in 2 cases. A blind spot in the operative corridor was the most common cause of residual BSCM (9 patients). All recurrent BSCMs were removed completely, although 2 patients each required 2 operations to treat recurrence. Twelve patients had unchanged or improved modified Rankin Scale scores at last clinical evaluation compared with admission, and 2 patients had worse scores. Recurrence was more common among patients who were operated on in the first versus the second half of the series (8.5% vs 4.7%).

CONCLUSIONS

The 6.6% rate of BSCM recurrence requiring reoperation reflects the fine lines between complete resection and recurrence and between safe and harmful surgery. The detection of remnants is difficult postoperatively and remains so even at 6 months when the resection bed has healed. The 5.9% annual hemorrhage risk associated with recurrent BSCM in this experience is consistent with that reported for unoperated BSCMs. The right-angle method helps to anticipate blind spots and meticulously inspect the resection cavity for residual BSCM during surgery. A low percentage of recurrent BSCM (5%–10%) ensures ongoing effort toward an acceptable balance of safety and completeness.

ABBREVIATIONS BSCM = brainstem cavernous malformation; CN = cranial nerve; mRS = modified Rankin Scale.

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

USD  $505.00

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

USD  $600.00

Contributor Notes

Correspondence Michael T. Lawton: c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online November 20, 2020; DOI: 10.3171/2020.6.JNS201555.

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

  • 1

    Gross BA, Batjer HH, Awad IA, Bendok BR. Brainstem cavernous malformations. Neurosurgery. 2009;64(5):E805E818.

  • 2

    Gross BA, Batjer HH, Awad IA, . Brainstem cavernous malformations: 1390 surgical cases from the literature. World Neurosurg. 2013;80(1-2):8993.

    • Search Google Scholar
    • Export Citation
  • 3

    Gross BA, Du R. Hemorrhage from cerebral cavernous malformations: a systematic pooled analysis. J Neurosurg. 2017;126(4):10791087.

  • 4

    Abla AA, Lekovic GP, Turner JD, . Advances in the treatment and outcome of brainstem cavernous malformation surgery: a single-center case series of 300 surgically treated patients. Neurosurgery. 2011;68(2):403415.

    • Search Google Scholar
    • Export Citation
  • 5

    Garcia RM, Ivan ME, Lawton MT. Brainstem cavernous malformations: surgical results in 104 patients and a proposed grading system to predict neurological outcomes. Neurosurgery. 2015;76(3):265278.

    • Search Google Scholar
    • Export Citation
  • 6

    Wang CC, Liu A, Zhang JT, . Surgical management of brain-stem cavernous malformations: report of 137 cases. Surg Neurol. 2003;59(6):444454.

    • Search Google Scholar
    • Export Citation
  • 7

    Pandey P, Westbroek EM, Gooderham PA, Steinberg GK. Cavernous malformation of brainstem, thalamus, and basal ganglia: a series of 176 patients. Neurosurgery. 2013;72(4):573589.

    • Search Google Scholar
    • Export Citation
  • 8

    Cenzato M, Stefini R, Ambrosi C, Giovanelli M. Post-operative remnants of brainstem cavernomas: incidence, risk factors and management. Acta Neurochir (Wien). 2008;150(9):879887.

    • Search Google Scholar
    • Export Citation
  • 9

    Abla AA, Lekovic GP, Garrett M, . Cavernous malformations of the brainstem presenting in childhood: surgical experience in 40 patients. Neurosurgery. 2010;67(6):15891599.

    • Search Google Scholar
    • Export Citation
  • 10

    Bertalanffy H, Gilsbach JM, Eggert HR, Seeger W. Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir (Wien). 1991;108(3-4):9199.

    • Search Google Scholar
    • Export Citation
  • 11

    van Swieten JC, Koudstaal PJ, Visser MC, . Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604607.

    • Search Google Scholar
    • Export Citation
  • 12

    Steinberg GK, Chang SD, Gewirtz RJ, Lopez JR. Microsurgical resection of brainstem, thalamic, and basal ganglia angiographically occult vascular malformations. Neurosurgery. 2000;46(2):260271.

    • Search Google Scholar
    • Export Citation
  • 13

    Brown AP, Thompson BG, Spetzler RF. The two-point method: evaluating brain stem lesions. BNI Q. 1996;12(1):2024.

Metrics

All Time Past Year Past 30 Days
Abstract Views 381 381 381
Full Text Views 66 66 66
PDF Downloads 27 27 27
EPUB Downloads 0 0 0