A retrospective and consecutive analysis of the epidemiology and management of spinal cavernomas over the last 20 years in a single center

A Rare Instance of Spinal Cord Cavernous Malformation With Adjacent Intramedullary Microhemorrhage

The natural history of spinal cord cavernous malformation (SCM) may be characterized by recurrent episodes of hemorrhage resulting in a range of neurologic deficits, most of which are microhemorrhage and subsequent gliosis that can lead to progressive myelopathy. Macrohemorrhage with acute onset of symptoms is extremely rare and leads to irreversible neurologic deficits. In this article, we present an unusual case of ruptured cavernous malformation (CM) in the cervical spinal cord with large extralesional hemorrhage. The patient underwent an operation of posterior longitudinal myelotomy and had a good neurologic recovery. A histologic examination revealed the typical features of cavernous angioma.

Vascular Myelopathies

OBJECTIVE

Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord.

LATEST DEVELOPMENTS

Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension.

ESSENTIAL POINTS

Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.

Functional impact of multiple bleeding events in patients with conservatively treated spinal cavernous malformations

OBJECTIVE

The aim of this study was to investigate the functional outcome in spinal cavernous malformation (SCM) patients with single or multiple intramedullary hemorrhagic events.

METHODS

SCM patients who were conservatively treated between 2003 and 2021 and had complete clinical baseline characteristics, an MRI data set, at least one SCM-related intramedullary hemorrhage (IMH), and at least one follow-up examination were included in this study. Functional status was assessed using the modified McCormick Scale score at diagnosis, before and after each bleeding event, and at the last follow-up.

RESULTS

A total of 45 patients were analyzed. Univariate analysis identified multiple bleeding events as the only statistically significant predictor for an unfavorable functional outcome at the last follow-up (OR 15.28, 95% CI 3.22-72.47; p < 0.001). Patients significantly deteriorated after the first hemorrhage (29.0%, p = 0.006) and even more so after the second hemorrhage (84.6%, p = 0.002). Multiple bleeding events were significantly associated with functional deterioration at the last follow-up (76.9%, p = 0.003). The time between the last IMH and the last follow-up did not influence this outcome.

CONCLUSIONS

IMH due to SCM is linked to functional worsening. Such outcomes tend to improve after each hemorrhage, but the probability of full recovery declines with each bleeding event.

Prediction of outcomes for symptomatic spinal cavernous malformation surgery: a multicenter prospective clinical study

PURPOSE

Clinical outcome of spinal cavernous malformation (SCM) varies because of its unclear natural history, and reliable prognostic prediction model for SCM patients is limited. The aim of the present study was to investigate potential factors that predict one-year neurological status in postoperative patients with SCM.

METHODS

This was a multicenter prospective observational study in consecutive patients with SCMs. SCMs treated microsurgically between January 2015 and January 2021 were included. Outcome was defined as the American Spinal Injury Association Impairment Scale (AIS) grade at one year after operation. Multivariable analyses were used to construct the best predictive model for patient outcomes.

RESULTS

We identified 268 eligible SCM patients. Neurological outcome had worsened from preoperative baseline in 51 patients (19.0%) at one year. In the multivariable logistic regression, the best predictive model for unfavorable outcome included symptom duration ≥ 26 months (95% CI 2.80-16.96, P < 0.001), size ≤ 5 mm (95% CI 1.43-13.50, P = 0.010), complete intramedullary (95% CI 1.69-8.14, P = 0.001), subarachnoid hemorrhage (95% CI 2.92-12.57, P < 0.001), AIS B (95% CI 1.91-40.93, P = 0.005) and AIS C (95% CI 1.12-14.54, P = 0.033).

CONCLUSIONS

Admission size of the lesion, morphology, symptom duration, AIS grade and the presence of subarachnoid hemorrhage were strong outcome predictors regarding prognostication of neurological outcome in postoperative patients with SCMs. A decision to surgically remove a symptomatic SCM should be justified by systematic analysis of all factors potentially affecting outcome.

A systematic review on the outcome of intramedullary spinal cord cavernous malformations

PURPOSE

This study aimed to investigate the neurological outcome, trends and sequelae following surgical or conservative treatment of intramedullary spinal cord cavernous malformations (ISCCMs).

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome measure was the change in the neurological status after surgery or conservative management. A logistic regression analysis investigating prognostic factors related to outcome was also performed.

RESULTS

Twenty-one studies with 1091 patients in total were included, of which 1005 (92.1%) underwent surgical resection and 86 (7.9%) were treated conservatively. Gross total resection was achieved in 95.7% of the patients and partial resection in 4.3%. Most lesions (60.2%) were located in the thoracic spine and presented with motor (60.4%) and sensory deficits (59.7%). In the long term, surgical treatment resulted in an improved neurological status in 36.9% of the patients, in 55.8% it remained stable, and in 7.3% it deteriorated compared to the preoperative state. In the conservative cohort, 21.7% improved, 69.6% remained stable, and 8.7% deteriorated. Solitary lesions, duration of preoperative symptoms less than 3 months as well as an improved post-operative neurological status were predictors of a favourable long-term outcome.

CONCLUSIONS

Whenever feasible, symptomatic patients with ISCCM are recommended to undergo surgery within 3 months from symptom onset. Absence of multiple lesions and, most importantly, post-operative symptom improvement foresee a favourable long-term outcome. Further research is warranted to discern the role of conservative treatment in symptomatic patients.

Radiation exposure in the endovascular therapy of cranial and spinal dural arteriovenous fistula in the last decade: a retrospective, single-center observational study

PURPOSE

This study aims to determine local diagnostic reference levels (DRLs) in the endovascular therapy (EVT) of patients with cranial and spinal dural arteriovenous fistula (dAVF).

METHODS

In a retrospective study design, DRLs and achievable dose (AD) were assessed for all patients with cranial and spinal dAVF undergoing EVT (I) or diagnostic angiography (II). All procedures were performed at the flat-panel angiography-system Allura Xper (Philips Healthcare). Interventional procedures were differentiated according to the region of fistula and the type of procedure.

RESULTS

In total, 264 neurointerventional procedures of 131 patients with dAVF (94 cranial, 37 spinal) were executed between 02/2010 and 12/2020. The following DRLs, AD, and mean values could be determined: for cranial dAVF (I) DRL 507.33 Gy cm2, AD 369.79 Gy cm2, mean 396.51 Gy cm2; (II) DRL 256.65 Gy cm2, AD 214.19 Gy cm2, mean 211.80 Gy cm2; for spinal dAVF (I) DRL 482.72 Gy cm2, AD 275.98 Gy cm2, mean 347.12 Gy cm2; (II) DRL 396.39 Gy cm2, AD 210.57 Gy cm2, mean 299.55 Gy cm2. Dose levels of EVT were significantly higher compared to diagnostic angiographies (p < 0.001). No statistical difference in dose levels regarding the localization of dAVF was found.

CONCLUSION

Our results could be used for establishing DRLs in the EVT of cranial and spinal dAVF. Because radiation exposure to comparably complex interventions such as AVM embolization is similar, it may be useful to determine general DRLs for both entities together.

Intramedullary spinal cord cavernous malformations-association between intraoperative neurophysiological monitoring changes and neurological outcome

BACKGROUND

Microsurgical resection of spinal cord cavernous malformations can be assisted by intraoperative neurophysiological monitoring (IONM). While the clinical outcome after surgical resection has been discussed in several case series, the association of intraoperative IONM changes and detailed neurological outcome, however, has not been analyzed so far.

METHODS

Seventeen patients with spinal cavernomas underwent surgery between 02/2004 and 06/2020. Detailed neurological and clinical outcome as well as IONM data including motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring were retrospectively analyzed. Intraoperative IONM changes were compared to outcome at 3-month and 1-year follow-up in order to identify surrogate parameters for an impending neurological deficit.

RESULTS

Compared to the preoperative state, McCormick score at 1-year follow-up remained unchanged in 12 and improved in five patients, none worsened, while detailed neurological examination revealed a new or worsened sensorimotor deficit in 4 patients. The permanent 80% amplitude reduction of MEP and 50% amplitude reduction of SSEP showed the best diagnostic accuracy with a sensitivity of 100% and 67% respectively and a specificity of 73% and 93% respectively. The relative risk for a new neurological deficit at 1-year follow-up, when reversible IONM-deterioration was registered compared to irreversible IONM deterioration, was 0.56 (0.23-1.37) for MEP deterioration and 0.4 (0.18-0.89) for SSEP deterioration.

CONCLUSIONS

Reversible IONM changes were associated with a better neurological outcome at follow-up compared to irreversible IONM deterioration during SCCM surgery. Our study favors the permanent 80% amplitude reduction criterion for MEP and 50% amplitude reduction criterion for SSEP for further prospective evaluation of IONM significance and the effectiveness of corrective maneuvers during SCCM surgeries.

Natural course of untreated spinal cord cavernous malformations: a follow-up study within the initial 5 years after diagnosis

OBJECTIVE

Cavernous spinal cord malformations (SCMs) are believed to have a high rate of bleeding. The risk of intramedullary hemorrhage (IMH) or recurrent IMH and the neurological impact of bleeding events are important for clinical decision-making and could impact current treatment strategies.

METHODS

The authors screened their institutional database for patients with cavernous SCM treated between 2003 and 2020. Patients with complete MRI data sets and clinical baseline characteristics were included. Surgically treated patients were censored after cavernous SCM removal. Neurological functional status was obtained using the modified McCormick (MMcC) scale at diagnosis, first IMH, and second IMH. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for hemorrhage or rehemorrhage.

RESULTS

Seventy-one patients with cavernous SCM were analyzed. Cox regression analysis identified previous IMH (hazard ratio 7.86, 95% confidence interval 1.01-61.47, p = 0.049) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of bleeding or rebleeding was 41.3% for cavernous SCM. The MMcC score significantly deteriorated in 75% of patients after recurrent hemorrhage (p = 0.012).

CONCLUSIONS

During untreated 5-year follow-up, a considerably increased risk for hemorrhage or rehemorrhage was found in cavernous malformations of the spinal cord compared to cerebral cavernous malformations. Neurological function significantly deteriorates after the second bleeding. The probability of recurrent IMH increased significantly after initial presentation with hemorrhage.

Treatment strategies and prognostic factors for spinal cavernous malformation: a single-center retrospective cohort study

OBJECTIVE

The authors aimed to identify factors that influence neurological function after treatment in order to facilitate clinician decision-making during treatment of spinal cavernous malformation (SCM) and about when and whether to perform surgical intervention.

METHODS

The authors performed a retrospective observational cohort study of patients with SCM who were treated at their institution between January 2004 and December 2019. Multiple logistic and Cox regression analyses were performed to determine the prognostic predictors of clinical outcome. Neurological status was assessed according to Frankel grade.

RESULTS

A total of 112 patients met the inclusion criteria, and a minimum 24 months of follow-up was achieved by 73 surgically treated and 39 conservatively treated patients. The mean ± SD lesion size was 8.7 ± 5.2 mm. In the surgically treated group, preoperative lesion size ≤ 5 mm (OR 13.62, 95% CI 1.05-175.98, p = 0.045), complete intramedullary lesion (OR 7.48, 95% CI 1.39-40.15, p = 0.019), and subarachnoid hemorrhage (OR 6.26, 95% CI 1.13-34.85, p = 0.036) were independent predictors of worse outcome. In the conservative treatment group, lesion size ≥ 10 mm (HR 9.77, 95% CI 1.18-80.86, p = 0.034), ≥ 3 segments with hemosiderin deposition (HR 13.73, 95% CI 1.94-97.16, p = 0.009), and subarachnoid hemorrhage (HR 13.44, 95% CI 2.38-75.87, p = 0.003) were significant predictors of worse outcome. The annual hemorrhage rate of the conservatively treated patients was 4.3%.

CONCLUSIONS

Subarachnoid hemorrhage, lesion size, morphology, extent of hemosiderin involvement, and motor dysfunction were independent risk factors of prognosis. In clinical practice, these parameters may help to identify patients at high risk for worse outcome. The treatment strategy for patients with SCM should be based on these risk factors and balanced with clinical symptoms.

Long-term surgical outcomes and prognostic factors of adult symptomatic spinal cord cavernous malformations

Cervical and thoracic or lumbar intramedullary spinal cavernous malformations (ISCMs) may behave differently. We conducted this retrospective study by using data from adult ISCMs to compare their natural histories and explore prognostic factors for improved clinical outcomes. Neurological functions were assessed by using the Modified McCormick Scale (MMCS) and Aminoff-Logue Disability Scale. A total of 111 study-eligible adult patients were included in this study. Patients with cervical ISCMs mostly demonstrated a shorter duration of symptoms (P = 0.026), an acute onset pattern with some recovery (P = 0.026), and a larger lesion size (P = 0.033) than their thoracic or lumbar counterparts. Thoracic or lumbar lesions had a higher proportion of motor symptoms (P = 0.001) and sphincter problems (P = 0.005), and they were usually associated with an aggressive clinical course (P = 0.001, OR = 9.491, 95% CI = 2.555-35.262) in multivariate analysis. There was no difference in age, sex distribution, hemorrhage risk between the cervical and thoracic-lumbar groups. A better preoperative neurological status (P = 0.034, OR = 2.768, 95% CI = 1.081-7.177) and improvement immediately after surgery (P < 0.001, OR = 8.756, 95% CI = 4.837-72.731) were identified as indicators for long-term improvement by multivariate analysis. Cervical lesions had a high proportion for long-term improvement, but it was not a predictor for improvement in multivariate analysis. ISCMs in the thoracic or lumbar location should be considered for surgical removal more aggressively than those in the cervical location. Surgical removal of symptomatic ISCMs can avoid further neurological deterioration and usually result in satisfactory long-term outcomes.

Outcome in Patients with Spinal Cavernomas Presenting with Symptoms Due to Mass Effect and/or Hemorrhage: Conservative versus Surgical Management: Meta-analysis of Direct Comparison of Approach-Related Complications

OBJECTIVE

We sought to examine the conservative treatment of symptomatic spinal cavernomas and evaluate the efficacy and safety of surgical management of spinal cord cavernous malformations.

METHODS

This meta-analysis included articles comparing outcomes of conservative treatment and surgical management of spinal cavernomas, published in the full-text form (from 2000 to June 31, 2020). Collected variables included first author name, country, covered study period, publication year, the total number of patients and at follow-up, bleeding, motor weakness, pain, bladder and/or bowel dysfunction neurologic improvement or deterioration after discharge, and the need for reintervention after subtotal surgical resection or hemorrhage.

RESULTS

After the initial searching and applying all exclusion and inclusion criteria, there were 9 articles left in the final article pool. The total number of patients was 396 with 264 (66.6%) undergoing surgical resection and 132 (33.4%) electing conservative management. Regarding motor weakness, bladder/bowel dysfunction, deterioration, and reintervention, the final results demonstrated no potential significant difference between the 2 groups. In regard to the subgroup of patients with bleeding, improvement, and pain, the results of the analysis showed a statistically significant difference between the 2 groups.

CONCLUSIONS

Patients who have experienced a hemorrhagic episode should consider surgical intervention, which decreases the risk of recurrent hemorrhage and further neurologic deterioration. In addition, surgical decompression obtained by resection of the hemorrhage and cavernoma seems to lead to slight neurologic improvement in some patients. In nonhemorrhagic cavernomas, conservative treatment might be optimal due to surgery-related morbidity risks.

How I do it: dorsolateral approach for ventrolateral intramedullary cavernoma

BACKGROUND

For small and lateral lesions, in order to avoid postoperative sequelae related to dorso-median myelotomy, we propose to describe the use of a ventrolateral approach for intramedullary lesions.

METHOD

Performing this approach entails that the denticulate ligament is cut from its dural attachment and retracted. Rotation of the spinal cord must be achieved with great caution and under electrophysiological monitoring. After pia mater incision, hydrodissection is useful to gently dissect the cavernoma and promote a cleavage plane.

CONCLUSION

In the case of lateral intramedullary lesions, using this approach maximized the absence of postoperative deficit.

Clinical outcomes and prognostic factors for cavernous hemangiomas of the spinal cord: a retrospective cohort study

OBJECTIVE

Intramedullary cavernous hemangioma (CH) is a rare vascular lesion that is mainly characterized by the sudden onset of hemorrhage in young, asymptomatic patients, who then experience serious neurological deterioration. Despite the severity of this condition, the therapeutic approach and timing of intervention for CH remain matters of debate. The aim of this study was to evaluate the clinical characteristics of CH patients before and after surgery and to identify prognostic indicators that affect neurological function in these patients.

METHODS

This single-center retrospective study included 66 patients who were treated for intramedullary CH. Among them, 57 underwent surgery and 9 patients received conservative treatment. The authors collected demographic, symptomology, imaging, neurological, and surgical data. Univariate and multivariate logistic regression analyses were performed to identify the prognostic indicators for neurological function.

RESULTS

When comparing patients with stable and unstable gait prior to surgery, patients with unstable gait had a higher frequency of hemorrhagic episodes (52.4% vs 19.4%, p = 0.010), as assessed by the modified McCormick Scale. The lesion was significantly smaller in patients who underwent conservative treatment compared with surgery (2.5 ± 1.5 mm vs 5.9 ± 4.1 mm, respectively; p = 0.024). Overall, the patients experienced significant neurological recovery after surgery, but a worse preoperative neurological status was identified as an indicator affecting surgical outcomes by multivariate analysis (OR 10.77, 95% CI 2.88–40.36, p < 0.001). In addition, a larger lesion size was significantly associated with poor functional recovery in patients who had an unstable gait prior to surgery (8.6 ± 4.5 mm vs 3.5 ± 1.6 mm, p = 0.011).

CONCLUSIONS

Once a hemorrhage occurs, surgical intervention should be considered to avoid recurrence of the bleeding and further neurological injury. In contrast, if the patients with larger lesion presented with worse preoperative functional status, surgical intervention could have a risk for aggravating the functional deficiencies by damaging the thinning cord parenchyma. Conservative treatment may be selected if the lesion is small, but regular neurological examination by MRI is needed for assessment of a change in lesion size and for detection of functional deterioration.

ABBREVIATIONS

AIS = ASIA Impairment Scale; ASIA = American Spinal Injury Association; CH = cavernous hemangioma; EBL = estimated blood loss; JOA = Japanese Orthopaedic Association; mMS = modified McCormick Scale.

Anterior to Dorsal Root Entry Zone Myelotomy (ADREZotomy): A New Surgical Approach for the Treatment of Ventrolateral Deep Intramedullary Spinal Cord Cavernous Malformations

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

To confirm the feasibility of using anterior to dorsal root entry zone myelotomy (ADREZotomy), a new surgical approach, for the treatment of ventrolateral deep intramedullary spinal cord cavernous malformation (ISCCMs).

SUMMARY OF BACKGROUND DATA

Surgical removal of ventrolateral deep ISCCMs is highly risky and remains problematic.

METHODS

The authors performed a retrospective study exploring the surgical removal of ventrolateral intrinsic ISCCMs using ADREZotomy in 10 patients. The Frankel grading system was used to evaluate the patients' neurological function at the preoperative, postoperative and follow-up stages. American Spinal Injury Association Scale scores at the preoperative and postoperative were also obtained. The patient characteristics and surgical outcomes were analyzed. The indication, operative steps, complications, and anatomical basis of the myelotomies were described and discussed.

RESULTS

In total, nine (90%) patients presented with mild symptoms before surgery. Gross total resections were performed in all 10 patients. Immediately after surgery, the neurological function of eight (80.0%) patients remained the same. One patient improved and one (10%) patient worsened. There were no other immediate or delayed complications related to the surgical procedure. No decrease of total American Spinal Injury Association sensory scores was observed. The follow-up neurological function evaluation showed that two (20%) patients improved from a Frankel grade of D to E and eight (80.0%) patients were stable. No recurrences or other additional neurological deterioration was observed.

CONCLUSION

Surgical removal of ventrolateral deep ISCCMs can be feasible using proper surgical techniques. ADREZotomy is a minimally invasive technique for the removal of cervical and thoracic ventrolateral deep ISCCMs, without disrupting the important spinal cord tracts or the need to broadly expose bone.

LEVEL OF EVIDENCE

4.

Spinal Cavernomas: Outcome of Surgically Treated 10 Patients

Aim

We report the preoperative and postoperative findings and also neurological follow-up results from 10 spinal cavernoma patients treated in our clinic. Several representative cases are presented in terms of clinical features, imaging results, and surgical outcomes.

Material and methods

The data were retrospectively collected from patients' files in the hospital records and sorted with regards to clinical presentation, radiologic features, and operative findings. Patients received spinal MRI scans for the diagnosis of spinal cavernomas (SC) and postsurgical evaluation. Clinical presentation was evaluated via Ogilvy classification and symptoms were checked preoperatively and postoperatively at third month and first year using McCormick scale. Primary treatment was microsurgical operation aiming a gross total lesion resection.

Results

10 spinal cavernoma patients between the ages 30 and 63 were treated. Six (60%) of the patients were diagnosed with cervical and four (40%) others were diagnosed with thoracic SC. Among the patient group, mean preoperative Ogilvy classification score was 2.3 ± 0.7.8 and McCormick score was 1.9 ± 0.7. There was no residual mass or relapse after surgery. One patient developed surgery-related left hemiparesis, which was normalized at 1 year follow-up.

Conclusion

Patients must be diagnosed with MRI since it is nowadays a gold standard. Preoperative and postoperative scores are important in evaluating the patients' condition and improvement. The results from our patient series also reinforce the notion that immediate surgery should be the preferred treatment method for cavernomas. Intraoperative neurophysiologic monitarization should assist the surgery in order to prevent complications. In conclusion, microsurgery is a gold standard method that we recommend for cases of cavernomas, which will not recur if gross total resection is achieved.

High-energy Trauma Precipitating Intramedullary Cavernous Malformation Hemorrhage - A Possible Underreported Mechanism

Cavernous malformations are uncommon vascular lesions with an estimated prevalence of 0.5% in the general population. Intramedullary cavernous malformations (ICM) represent a rare subset of lesions, which account for approximately 5% of all cavernous malformations. The annual risk of hemorrhage in ICMs has been reported to range from 1.4 to 6.8%. Most patients are diagnosed with neurological dysfunction secondary to ICM hemorrhage and little is known about the inciting events that lead to hemorrhage. A few studies have suggested that minor and major trauma or even intense exertion may increase the risk of hemorrhage. We report the case of a 62-year-old male who developed progressive neurological deterioration following a motor vehicle accident. During work-up, an ICM was found at T4 and was surgically removed. At his 10-month follow-up, the patient had partially recovered, regaining motor strength in his right lower extremity, but had a persistent decrease in temperature and pinprick sensation on the left side starting at the T6 dermatome. We hypothesize that ICMs can rupture after high-energy impacts, such as the motor vehicle accident in our patient, and mechanical factors, such as trauma and stretching maneuvers, can play a role in the pathogenesis of ICM hemorrhage. 

Factors affecting functional outcome in patients with intramedullary spinal cord tumors: results from a literature analysis

Recently, great advances have been made in the surgical treatment of intramedullary spinal cord tumors (IMSCTs). Many articles have been published; but looking at the literature of the last 5 years, there are only descriptive reviews and no works in which a literature statistical analysis was performed. Here, we analyzed the literature to identify potential prognosticators of good functional outcome in IMSCT patients. To level out the selected studies, we stratified patients' neurological status as independent (ambulation possible without caregiver assistance) or disabled (cannot ambulate or can only ambulate with caregiver assistance). 18 out of 125 articles were included in the analysis (691 patients). A significant higher percentage of gross total resection (GTR) in ependymomas, hemangioblastomas and cavernomas compared to the astrocytomas (particularly high-grade gliomas) was observed. We found a strong correlation between a good pre-operative neurological function and a good post-operative and at follow-up (FU) neurological status and between GTR and a good post-operative and at FU neurological status. A significant better outcome was found in ependymomas, hemangioblastomas and cavernomas compared to astrocytomas. Our analysis suggests that an early surgery could be reasonable in IMSCTs, because a good pre-operative neurological function is a strong predictor of good neurological outcome. In patients with high-grade gliomas, there is no indication to attempt a GTR due to the infiltrative growth pattern of this tumor that leads to a higher surgical morbidity. Although not innovative, the evidences of our literature statistical analysis strengthen the results from previous surgical series and descriptive reviews.